Although dermatologic manifestations are now recognized as part of COVID-19, specifics of nail manifestations in particular are not widely known. In an article published in Dermatologic Therapy, dermatologists review the most updated knowledge on nail involvement for those with COVID-19 and the recommended treatment options.

Microvascular Disturbances

  • An open trial of 82 COVID-19 patients in Italy reported pericapillary edema (80.5%), enlarged capillaries (61%), and sludge flow (53.7%), as well as meandering capillaries and reduced capillary density in every second patient.
  • Hemosiderin deposits from micro-hemorrhages and micro-thrombosis has been reported.
  • Patients recovered from COVID-19 reported a higher frequency of capillary pathologies including enlarged capillaries, meandering capillaries, capillary loss, and empty dermal papillae.
  • Microvascular disturbances may be detected via nailfold capillaroscopy.

COVID-toe or -finger


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  • A pernio-like periungual erythematous edema on the fingers or toes.
  • Typically occurs as part of a resolution phase or a milder/asymptomatic course of COVID-19.
  • Histopathological findings of 17 patients with pernio-like acral lesions and suspected SARS-CoV-2 infection revealed deep horizontal parakeratosis (71%), necrosis of epidermal keratinocytes (41.5%), dispersed or confluent basal cell vacuolation (18%), spongiosis (12%), lymphocytic exocytosis (12%), dermal edema (76.5%), perivascular dermal lymphocytic infiltrate (100%), perivascular eosinophils (23.5%), endothelial cell swelling (65%), dermal mucin deposits (41.5%), microthrombi in superficial capillaries (12%) or venules (6%), dermal fibrin deposits (12%), and fibrin deposits in venule walls (18%).
  • Other studies reported cryofibrinogenemia; bilaterally localized distal erythematous or cyanotic lesions; red dots, white rosettes, and white streaks on dermatoscopy; histological remodeling of dermal blood vessels with a lobular arrangement, vascular wall thickening and a mild perivascular lymphocytic infiltrate; erythematous and purpuric papules on the toes or fingers, along with edema and pruritis or a burning sensation; and superficial dermal lymphocytic infiltrates around vessels and eccrine sweat glands.
  • About 50% of patients in these studies were positive for SARS-CoV-2, and most were young.

Acral Gangrene

  • A rare but severe symptom.
  • A red flag for acute severe infection with multisystemic inflammation and cardiovascular malfunction.

Treatment for Microvascular Nail Symptoms

  • Young, asymptomatic patients, or patients without confirmed SARS-CoV-2 infection – COVID-toe or -finger symptoms are self-limiting and will spontaneously resolve in 2 to 3 weeks.
  • Basic microvascular treatment in early COVID-19 stages – combination of antiviral therapies (favipiravir, remdesivir, hydroxychloroquine, lopanivir plus ritonavir) with antithrombotic treatment.
  • Basic microvascular treatment in later COVID-19 stages – antithrombotic therapy combined with treatments for cytokine storm (tocilizumab, dexamethasone, IL-1 or TNF-beta antagonists).
  • Cryofibrinogenemia – oral corticosteroids with low-dose acetylsalicylic acid.

Periungual Desquamation

  • Reported in children with MIS-C and adults recovering from severe COVID-19.
  • Treatment:
    • Moisturizers to limit the symptoms

Beau’s Lines

  • Transverse grooves of the nails
  • Single or multiple nails may be affected; mostly seen in fingernails
  • Can be accompanied by leukonychia
  • Observed in children and adults with COVID-19
  • Treatment
    • Mild and self-limiting; no specific treatment

Onychomadesis

  • Separation of the nail plate from the nail matrix with persistent attachment to the nail bed.
  • May be preceded by Beau’s lines.
  • A late manifestation of COVID-19 is heterogenous red-white discoloration of the nail bed with distal onycholysis.
  • Treatment
    • Mild and self-limiting
    • High-energy 633 nm red light (126 J/cm2 for 20 min every day) has been successful for fingernails but not toenails

Discolorations of the Lunula and Nail Plate

  • Red violet band surrounding the distal margin of the nail lunula and orange discoloration of the nail plate.
  • Lunula discoloration has been reported in adults with acute SARS-CoV-2.
  • Nail plate discoloration has been reported as a delayed response several weeks after COVID-19 diagnosis in elderly patients.
  • Non-blanchable transverse leukonychia has also been reported, and may persist following severe damage to the nail matrix.
  • Treatment
    • No specific treatment; colored nail lacquers can hide discoloration

Nail Changes Induced by COVID-19 Treatments

  • Favipiravir
    • Yellow-white fluorescence on the nails
    • Greenish-white fluorescence in the lunula and nail plate portion near the proximal nail fold
  • Hydroxychloroquine
    • Longitudinal melanonychia
  • Treatment
    • Nail changes will spontaneously resolve with withdrawal of the corresponding drug

Nail Changes Induced by COVID-19 Vaccination

  • Pernio-like lesions on the hands and/or feet were reported several days after vaccination with Pfizer-BioNTech and Moderna vaccines.
  • Treatment
    • Low-dose acetylsalicylic acid with oral corticosteroids for symptomatic and painful lesions
    • Treatment is often not necessary as symptoms are temporary

Nail Changes from COVID-19 Protective Measures

  • Green nail syndrome (Goldman-Fox syndrome)
    • Caused by nail infection or colonization with P. aeruginosa
    • Known as an occupational disease in healthcare workers and was reported in healthcare workers during the COVID-19 pandemic
    • Treatment
      • Oral ciprofloxacin
      • Topical treatments include removing the onycholytic part of the nail and brushing the nail bed with 2% hypochlorite solution twice daily for 6 weeks, as well as topical nadifloxacin, tobramycin, or gentamycin.
  • Brittle nails and cuticle loss
    • Due to chronic irritant proximal nail fold dermatitis
    • Treatment
      • Limit wet work and use of protective gloves
      • Moisturizers during the day and emollients overnight

Reference

Wollina U, Kanitakis J, Baran R. Nails and COVID-19 – A comprehensive review of clinical findings and treatment. Published online Aug 16, 2021. Dermatol Ther. doi:10.1111/dth.15100