Podiatry and the pandemic

Conway McLean, DPM

If anyone is stranded on a desert island, they are likely the only person on the planet who isn’t inundated with news about the pandemic.

How much of the information released is accurate? Because this virus is newly discovered, there is much ignorance about COVID-19. How exactly does the contagion spread? What is the best therapy for someone with significant signs and symptoms? Questions abound, while we grasp for answers like straws. Facts are few and often unreliable when it comes to this novel viral infection.

In some regions of the world, health care workers have been pushed to the limit. In others, they sit idle, their offices closed or nearly so, in concert with the ‘Stay-At-Home’ Orders.

To date, some areas of the US have been harder hit, with a much higher percentage of confirmed cases (eg New York city). Doctors and nurses in such areas sometimes end up working with trash bags on their feet, a sad excuse for personal protective equipment, the well-publicized PPE.

In these areas of higher infection rates, podiatrists are there on the front lines, caring for patients. Modern podiatric medical training includes three years of residency training, typically based in a large hospital, learning alongside other residents, be they internal medicine, neurology, orthopedics, etc.

Many are surprised a podiatrist would be involved in such a manner. But is this the only way a podiatrist would be caring for a patient with COVID-19? It turns out there is a “podiatric” manifestation of this coronavirus.

Of all the unexpected health impacts from the pandemic, “COVID Toes” may be among the oddest. This is a dermatologic condition which would seem to demand the attention of a podiatrist. Providers have reported on reddened, painful bumps on the toes of younger individuals.

These lesions seem to start off as bright red, but evolve into more of a purplish color. They may develop on the tips of one or more toes, and on occasion, affect all the toes.

A variant of this condition appears on the bottom of the feet. These discolored areas may be itchy or distinctly tender, but do heal without scarring.

COVID Toes occurs mainly in children and young people, generally in those under 26 years of age. Researches have reported COVID Toes in the absence of any other COVID-19 symptoms, while in others, these skin lesions precede the appearance of the more common systemic symptoms of a respiratory infection.

Fortunately, as many people have read, this sector of the population is one who generally does not develop severe symptoms from the infection.

Many of the patients with this strange rash had symptoms consistent with COVID weeks prior to the appearance of these lesions. Others had no prior symptoms but probable exposure to the virus.

The children who developed these painful lesions of the feet or toes did not have the typical symptoms such as high fever, cough, shortness of breath, or fatigue.

Scientists have noted other dermatologic manifestations of COVID-19. There have been reports of conjunctivitis (pink eye) and other skin rashes.

But dermatologic changes are quite common in many viral infections, especially respiratory. Some examples would be measles or shingles, both of which are skin manifestations of a virus.

With a viral pandemic this new, many questions arise. Why do the skin changes of the COVID-19 virus occur? It may have something to do with how the virus stimulates a localized inflammatory response in the toes. In the process of mounting an antibody response to the virus, secondary inflammation may develop.

Alternatively, this skin reaction could be caused by micro-clots, basically small clogs, in the blood vessels found in the toes. COVID Toes are similar in appearance to a condition called chilblains, which causes dark red or purple toes, although those are associated with exposure to cold, wet conditions, not with a virus.

Some epidemiologists have been hoping seasonal changes would slow the spread of the pandemic, similar to the phenomenon of the “flu season”. A recent analysis of growth of the pandemic found no correlation between epidemic growth of COVID-19 and geographic latitude or temperature. Thus, we cannot hope for a reduction of new cases in response to a change in seasons. In contrast, public health interventions such as restrictions of mass gatherings, school closures and social distancing have clearly been the most effective measures of reducing transmission.

Different countries have used varying approaches in response to this coronavirus. Back in mid-January, South Korea, the UK and America all reported their first cases. By the end of February, South Korea had the most cases of any country outside China, with new cases doubling every few days. But the US and UK responded very differently to its arrival and the numbers speak to the failure of their approach.

While the UK is reporting approximately 4,000 new cases a day, and the US stands at 30,000 per day, South Korea is now reporting less than 100 new cases a day. How did they manage this dramatic reduction in the spread of COVID-19, where other major world powers have failed to reign in the contagion? One key part of their strategy was extensive testing. South Korea was testing anyone and everyone, especially if there was any indication of contact with someone who tested positive, even if they didn’t have symptoms.

This ties into a technique called contact tracing, in which authorities aggressively search out all those individuals that an infected person had contact with. The South Korean government had the authority to get cell phone records, church membership lists, and various methods of tracing all the contacts of any afflicted individual. South Korean public-health officials recognized the necessity of early testing and the importance of isolating new patients to prevent secondary infections.

We suspect there is an association between ‘COVID Toes’ and the respiratory viral disease, but no definitive proof it is the cause yet exists. Thankfully, COVID Toes are seen mostly in an age group usually spared the brute force of the pandemic. But it does go to show how differently people can react to infections.

As to projections for the future of the COVID-19 pandemic, uncertainty abounds. One forecast posits a second wave of new cases larger than the first, occurring in mid-fall. Another suggests a gradual but irregular decrease in infections. How best to plan for the future of the COVID pandemic, and what strategies to implement? A cohesive and coherent plan has been instituted in too few countries. Many relevant and important questions remain.

The coronavirus pandemic is not over, regardless of our desire to return to normalcy. Economic concerns have weighed heavily on those in government, at the local, state and federal level. What about the consequences to our health, our lives? How best to balance these concerns? Public health interventions clearly remain a keystone of preventative efforts, as do the benefits of extensive, readily-available, accurate testing.

Supplies of both PPE and accurate tests have been grossly inadequate, by all measures. Perhaps a lifting of social distancing is possible, but should be tempered with an improved use of tests and protection. The plans we lay now will affect future generations, both psychosocially, economically, and culturally. A word of advice: proceed with caution!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.


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