Lesions on toes are shown in this undated handout photo. A Toronto doctor is suggesting that parents look at their children's feet to see if there are unusual lesions around the toes that could be a sign of possible COVID-19 infection. Dr. Elena Pope, the paediatric dermatology section head at the Hospital for Sick Children, said there has been an uptick in skin presentations of this nature - so-called COVID toes - in otherwise asymptomatic kids over the last few weeks in North America. THE CANADIAN PRESS/HO - Sick Kids Hospital

TORONTO - A Toronto doctor is suggesting that parents look at their children's feet to see if there are unusual lesions around the toes that could be a sign of possible COVID-19 infection.

Dr. Elena Pope, the paediatric dermatology section head at the Hospital for Sick Children, said there has been an uptick in skin presentations of this nature — so-called COVID toes — in otherwise asymptomatic kids over the last few weeks in North America.

"The kids are not really bothered by those lesions and I think that's why it took a while for this to come to the forefront," she said. "If they were not bothered by it, they maybe didn't actually report it to their parents ... most of the lesions disappear on their own. They fade over time."

Pope said there have been some cases where fingers are affected as well. The lesions have a red or purple colour and look similar to frostbite.

The Canadian Paediatric Surveillance Program (CPSP) issued a public health alert to clinicians this week, advising that these skin lesions should prompt COVID-19 testing. Pope and Dr. Irene Lara-Corrales, a paediatric dermatologist at Sick Kids, helped craft the alert.

"Overall I would emphasize that this seems to be an unusual manifestation in children who potentially have COVID infection and potentially are contagious at the time of the diagnosis, but they're otherwise asymptomatic and that it seems to resolve spontaneously over several weeks," Pope said.

Pope suggested that if lesions are discovered, virtual doctor care would be a good first step.

"From what we have gathered so far is the kids present with either itching or some mild pain in their toes associated with some swelling, and then they develop red or purple bumps that are persistent afterwards," Pope said. "Very few of them may actually have skin breakdown."

Definitive research in the area is still in the formative stages and specifics on case numbers have not been released. Registries have started around the world to track skin condition cases that may be connected to the novel coronavirus.

Pope said it was unusual to see such a significant uptick in similar skin presentations on a regular basis.

"I might see maybe less than five cases a year and nowadays we're seeing many, many, many patients with this manifestation," she said, speaking about the uptick here and in other countries.

They have decided that if the lesions are within the first two weeks of onset, it's worth testing those patients for COVID-19.

"There have been case reports from other highly endemic areas of the skin manifestation in association with the positive swabs from COVID. And also, in some of the cases, there was evidence of antibodies. So in other words, there was evidence that the patients were exposed to COVID and had antibodies to the virus.

"So I think it's fair enough to say that based on all those reasons, this is a true association with COVID. What is unusual about this presentation is that children are otherwise asymptomatic. So they don't have the classic symptoms of COVID."

Lesions may resemble chilblains or perniosis, a condition that doctors sometimes see in the spring when children are a little too eager to take off their boots and freeze their feet by wading in puddles of cold water, said Dr. Chantal Bolduc, a dermatologist at Universite de Montreal hospital centre.

"We are not sure it is a sign of COVID, but we think so because of the context," Bolduc said. "We see a little more cases than usual, and cold temperatures aren't a factor, and it's happening at the same time as the pandemic."

The majority of children showing the lesions don't have a cough or a fever, she said.

"From what has been reported so far, this is something that seems quite benign. The children are not sick. It suddenly appears and it seems a little odd, the children are in good health, it goes away on its own in two to four weeks," Bolduc said.

Symptoms may take up to 14 days to appear after exposure to COVID-19. They may also include cough, fever and shortness of breath.

"The good news for us is that the kids don't seem to have any other major manifestations and they simply recover quite fast from this, so that's reassuring," Pope said. "But it would be important for us to understand more about the mechanism and why this is happening and why it's happening primarily in children."

—With files from Jean-Benoit Legault in Montreal

This report by The Canadian Press was first published May 1, 2020.

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News from © The Canadian Press, 2020