“COVID-19 Toe” and Underrepresentation in People of Color: Is Racial Bias to Blame?

African American black woman foot
Cropped of black woman rubbing her foot, high heels syndromee
The association of COVID-19 and chilblains in patients with skin of color was evaluated.

Researchers in an editorial letter in the Journal of the American Academy of Dermatology are calling for more research into disparities regarding the prevalence of “COVID-19 toes” in patients of color.

In the letter, the investigators described their previously published study that found a lack of pernio-like diagnoses inpatients seen at the dermatology department in a New York City, minority-predominant safety-net hospital system (n=5635) from March to June, 2020.

The researchers also cited a similar study conducted in India that found that reported skin manifestations were uncommon in pigmented skin in 138 patients with coronavirus disease 2019 (COVID-19). As the dermatologists in this study were Indian, the researchers of the editorial letter suggest the lack of cutaneous manifestations may not be related to a lack of training in treating skin of color.

In a separate study, the researchers of the editorial letter retrospectively re-evaluated the association of COVID-19 and chilblains in people of color with COVID-19 diagnoses. The analysis included a total of 11 patients with skin of color and 1 White patient with chilblains or cutaneous vasculitis, all of whom were seen at a dermatology clinic from March to August 2020. Another 262 patients with skin of color and 27 White patients with COVID-19 who were seen at a dermatology clinic in this time frame were also analyzed. None of the patients with COVID-19 received a diagnosis of chilblains or cutaneous vasculitis.

Limitations of the study included the relatively small sample size as well as the retrospective nature of the analysis.

The researchers suggest that the results from their retrospective analysis, in addition to “the results from our Brazilian and Indian colleagues, suggest that the association of chilblain-like lesions with COVID-19 deserves further careful consideration.”


Cline A, Berk-Krauss J, Keyes Jacobs A, et al. The underrepresentation of “COVID toes” in skin of color: An example of racial bias or evidence of a tenuous disease association? Published online November 17, 2020. J Am Acad Dermatol. doi:10.1016/j.jaad.2020.11.003