J Jaad 2020 07 037

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Covid Toes: Phenomenon or Epiphenomenon?
Alana Deutsch, BA, Rachel Blasiak, MD MPH, Ashley Keyes, MD, Julia Wu, MD,
Shoshana Marmon, MD PhD, Falguni Asrani, MD, Janet Moy, MD, Marian Russo,
MD, Beth N. McLellan, MD
PII: S0190-9622(20)32206-4
DOI: https://doi.org/10.1016/j.jaad.2020.07.037
Reference: YMJD 14963
To appear in: Journal of the American Academy of Dermatology
Received Date: 15 June 2020

Revised Date: 11 July 2020
Accepted Date: 13 July 2020
Please cite this article as: Deutsch A, Blasiak R, Keyes A, Wu J, Marmon S, Asrani F, Moy J, Russo
M, McLellan BN, Covid Toes: Phenomenon or Epiphenomenon?, Journal of the American Academy of
Dermatology (2020), doi: https://doi.org/10.1016/j.jaad.2020.07.037.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
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© 2020 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.

1 Article type: Notes & Comments
2
3 Title: Covid Toes: Phenomenon or Epiphenomenon?
4
5 Alana Deutsch BA1, Rachel Blasiak MD MPH1,2, Ashley Keyes MD3, Julia Wu MD4,
6 Shoshana Marmon MD PhD5,6,7, Falguni Asrani MD5, Janet Moy MD8, Marian Russo
7 MD8, Beth N. McLellan MD1,2
8
9 1
Albert Einstein College of Medicine, Bronx, NY
10 2
Jacobi Medical Center, Division of Dermatology, Bronx, NY
11 3
Lincoln Medical Center, Department of Dermatology, Bronx, NY
12 4
Elmhurst Medical Center, Department of Dermatology, Elmhurst, NY
13 5
Woodhull Medical Center, Department of Dermatology, Brooklyn, NY
14 6
Coney Island Medical Center, Department of Dermatology, Brooklyn, NY
15 7
Cumberland Medical Center, Department of Dermatology, Brooklyn, NY
16 8
Metropolitan Medical Center, Department of Dermatology, New York, NY
17
18
19 Corresponding author:
20 Beth N. McLellan, MD
21 Email: [email protected]
22 Phone: (718) 918-4274
23 Mailing Address: 1400 Pelham Pkwy S, Rm 4W4D, Bronx, NY
24
25 Funding sources: None
26
27 Conflict of Interests and Financial Disclosures: There are no conflicts of or competing
28 interests to disclose.
29
30 Reprint requests: Beth N. McLellan, MD
31
32 Manuscript word count: 498
33 References: 4
34 Figures: 1
35 Tables: 1
36
37 Key words: Covid-19; acral perniosis; chilblain-like lesions, Covid toes; dermatology
38 To the editor:
39 As of June 15, there have been 206,606 cases and 22,103 deaths from Covid-19 in New
40 York City.1 The boroughs of the Bronx, Queens, and Brooklyn as well as Harlem in
41 upper Manhattan have been epicenters of disease since its emergence due to
42 socioeconomic factors that dictate its population’s baseline health and limit abilities to
43 maintain infection control measures. Accordingly, these areas account for 80.8% and
44 81.2% of cases and deaths from Covid-19 in NYC, respectively.1 As dermatologists
45 representing the New York City Health+Hospitals municipal healthcare system
46 throughout these heavily impacted areas, we have observed that the mounting
47 phenomenon of acral perniosis, colloquially known as ‘Covid toes,’ has been virtually
48 absent in our patient populations despite noteworthy subjugation in less affected areas.2
49 Illustratively, the seven medical centers we represent have seen no cases of Covid toes.
50 While usual dermatologic services have been curtailed during this pandemic period,
51 inpatient consults and ambulatory televisits have maintained care, therefore lack of access
52 to dermatologic services cannot account for this finding. Between March 16-June 5,
53 2020, there was a total of 5,635 dermatology televisits completed amongst our seven
54 hospitals, which ranged from 222-1250 televisits per hospital (Figure 1).
55
56 Importantly, an overwhelming majority of the serviced population is Hispanic and Black
57 (Table 1). A notable racial imbalance among reported cases of Covid toes is glaringly
58 apparent in a large, registry-based case series of 318 patients of which only 2.7% were
59 Hispanic and 0.7% were Black;3 thus, suggesting this phenomenon as a disease
60 manifestation of Caucasians. However, even if findings are resolute that this phenomenon
61 is specific to a single ethnic group, there is still question whether its relation to disease is
62 one of direct causality.
63
64 In the authors’ opinion, it remains difficult to qualify Covid toes as a direct manifestation
65 of disease at this time, especially as the rate of Covid-19 antigen test positivity among
66 affected patients is low. While recent reports corroborate low rates of confirmed disease,
67 they also explanatorily suggest that this manifestation occurs in otherwise mildly ill or
68 asymptomatic individuals late in disease course, which precludes antigen testing in a
69 timely fashion.3,4 There are other factors that could explain our findings – perhaps our
70 population has been less exposed to lay media reports of acral perniosis and its possible
71 association with Covid-19, or perhaps greater experience with severe Covid-19 in their
72 communities made them less likely to be concerned about mild manifestations.
73 Furthermore, our patients often seek care in the emergency department and fear of
74 exposure to infection may have prevented them from seeking evaluation. Nevertheless,
75 based on presently available data, it may be most appropriate to circumscribe this
76 phenomenon of Covid toes, rather, as an epiphenomenon, an accompanying symptom
77 without causal relation. Continued reporting of Covid toes cases, as well as antigen and
78 antibody testing of these individuals and ongoing pursuit of plausible alternative
79 explanations, remains crucial such that when a comprehensive, retrospective study
80 becomes achievable, the deductions can accurately portray pathophysiology of disease
81 and its manifestations.

82 References:
83 1. COVID-19: Data. 2020; https://www1.nyc.gov/site/coronavirus/index.page.
84 2. Cordoro KM, Reynolds SD, Wattier R, McCalmont TH. Clustered Cases of Acral
85 Perniosis: Clinical Features, Histopathology and Relationship to COVID-19.
86 Pediatr Dermatol. 2020.
87 3. Freeman EE, McMahon DE, Lipoff JB, et al. Pernio-like skin lesions associated
88 with COVID-19: a case series of 318 patients from 8 countries. J Am Acad
89 Dermatol. 2020.
90 4. Galvan Casas C, Catala A, Carretero Hernandez G, et al. Classification of the
91 cutaneous manifestations of COVID-19: a rapid prospective nationwide
92 consensus study in Spain with 375 cases. Br J Dermatol. 2020.

93 Figure Legend:
94 Figure 1. “Total number of ambulatory dermatology televisits at New York City Health +
95 Hospitals neighborhood hospitals from March 16, 2020- June 5, 2020.”

96 Table Legend:
97 Table 1. “Racial/ethnic breakdown of represented New York City Health and Hospitals
98 neighborhood hospitals as reported in the NYC H+H 2016 Community Health Needs
99 Assessment.”
Hispanic Non- Non- Asian/Pacific American Multi Patient

(%) Hispanic Hispanic Islander (%) Indian or Race/Other Decline
Black White Native (%) (%)
(%) (%) (%)
Jacobi 41.1 33.2 8.5 5.6 1.5 4.9 5.2

Coney Island 23.3 18.2 36.7 8.4 0.2 9.1 4.1
Woodhull 55.2 29.3 7.3 1.9 0.6 3.5 2.3

Lincoln 62.7 27.8 1.3 1.2 0.3 3.9 2.8
Elmhurst 52.1 6.5 9.7 14.9 1.0 10.7 5.1
Metropolitan 51.8 21.1 6.9 5.1 0.1 5.1 3.3
Cumberland 15.6 20.2 49.6 8.9 0.1 4.0 1.6

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Journal Pre-proof

Covid Toes: Phenomenon or Epiphenomenon?

To appear in: Journal of the American Academy of Dermatology

Received Date: 15 June 2020

© 2020 Published by Elsevier on behalf of the American Academy of Dermatology, Inc.

44 81.2% of cases and deaths from Covid-19 in NYC, respectively.1 As dermatologists

45 representing the New York City Health+Hospitals municipal healthcare system

56 Importantly, an overwhelming majority of the serviced population is Hispanic and Black

62 one of direct causality.

68 asymptomatic individuals late in disease course, which precludes antigen testing in a

72 communities made them less likely to be concerned about mild manifestations.

75 based on presently available data, it may be most appropriate to circumscribe this

76 phenomenon of Covid toes, rather, as an epiphenomenon, an accompanying symptom

78 antibody testing of these individuals and ongoing pursuit of plausible alternative

79 explanations, remains crucial such that when a comprehensive, retrospective study

80 becomes achievable, the deductions can accurately portray pathophysiology of disease

81 and its manifestations.

83 1. COVID-19: Data. 2020; https://www1.nyc.gov/site/coronavirus/index.page.

85 Perniosis: Clinical Features, Histopathology and Relationship to COVID-19.

86 Pediatr Dermatol. 2020.

88 with COVID-19: a case series of 318 patients from 8 countries. J Am Acad

90 4. Galvan Casas C, Catala A, Carretero Hernandez G, et al. Classification of the

91 cutaneous manifestations of COVID-19: a rapid prospective nationwide

92 consensus study in Spain with 375 cases. Br J Dermatol. 2020.

95 Hospitals neighborhood hospitals from March 16, 2020- June 5, 2020.”

Hispanic Non- Non- Asian/Pacific American Multi Patient

Jacobi 41.1 33.2 8.5 5.6 1.5 4.9 5.2

Woodhull 55.2 29.3 7.3 1.9 0.6 3.5 2.3

Cumberland 15.6 20.2 49.6 8.9 0.1 4.0 1.6

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