Atypical Wounds - COVID-19 skin changes

Skin changes seen in patients with COVID-19 may be misdiagnosed as pressure injuries. Possible mechanisms and differences are discussed, based on a white paper published by the National Pressure Injury Advisory Panel.
Atypical Wounds - COVID-19 skin changes

Last week the National Pressure Injury Advisory Panel issued a white paper on “Skin Manifestations with COVID-19: The Purple Skin and Toes that you see may not be Deep Tissue Pressure Injury.”[i] The stated purpose of the paper was “to guide the wound care clinician in determining if the ‘purple skin’ being seen is a deep tissue pressure injury or a cutaneous manifestation of COVID-19.”1 Some of the skin changes that have been reported include rashes, deep red or purple discoloration of the toes, erythema on the distal toes and fingers (termed acral areas) with vesicles or pustules, other vesicular eruptions, urticarial lesions, maculopapular eruptions, livedoid racemosa, and purpura fulminans appearance with or without necrosis. Often these changes occur over soft tissue that are not subjected to pressure; however, if they occur on bony prominences or on weight-bearing surfaces, they may be misdiagnosed as pressure injuries. One of the reported events is referred to as “COVID toes,” described as deep red or purple skin changes on the toes. A literature review by Sachdeva et al found that the onset of the skin lesions ranged from 3 days prior to COVID-19 diagnosis to 13 days after diagnosis, suggesting that processes other than pressure injury were the cause of the cutaneous manifestations of the disease.[ii]

Several suggested mechanisms that cause cutaneous changes related to the virus include the following:

  • Viral particles in the cutaneous blood vessels lead to a lymphocytic vasculitis similar to that seen in thrombophilic arteritis, a disorder in which blood immune complexes activate cytokines.2
  • An immune response to the infection leads to Langerhans cells activation, resulting in vasodilation and spongiosis.2
  • Accumulation of microthromboses that originate in other organs, as a result of a systemic procoagulant state, reduce the blood flow to the cutaneous microvascular system.2,[iii]
  • Low grade disseminated intravascular coagulation and hypoxia-related accumulation of deoxygenated blood leads to hypoperfusion in the extremities.2

The NPIAP white paper provides the following clinical guidelines for differentiating COVID-19 skin disorders from pressure injuries:

  • Purple areas that occur on non-pressure loaded surfaces do not have a pressure-shear etiology and thus should not be classified as pressure injuries.
  • Purple areas that occur on pressure-loaded surfaces (whether prone or supine) require further investigation. For example, was the skin change present on admission or did it occur after admission? Are temperature and texture changes consistent with pressure injuries? Magro reported histological differences between the COVID-19 specimens and deep pressure injury specimens, in which there is necrosis of skin, fat, and muscle.1,3
  • COVID toes. Deep red changes in the skin may be a result of vascular inflammation; whereas, deep purple changes may be indicative of micro-thrombi. If the patient is on vasopressors, purple toes may be a result of vasoconstriction and ischemia. Any of these scenarios would not be diagnosed as pressure injuries.1

Any critically ill patient is at higher risk for developing a pressure injury and thus it is imperative that all precautions discussed in previous posts be implemented to prevent tissue injury from pressure, shear, and friction. The sheep-skin type boots would be appropriate especially to protect from mechanical forces but also to hopefully stimulate vasodilation of the arteries and arterioles to the toes.

Days before this paper was published, a colleague shared with me that the physical therapy wound care specialist had been asked to see a patient with pressure injuries on the back, when indeed what the therapist saw was a diffuse rash - not something that fits the definition of a pressure injury. Not knowing that this phenomenon was common in COVID-19 patients, I suggested that the medications be reviewed to rule out a possible drug-induced hypersensitivity syndrome (DIHS), an allergic reaction to a medication that has been recently initiated (usually within the last two weeks). Because the patient population that is most vulnerable to severe complications from COVID-19 is also the patient population that is at risk for developing DIHS, this may still be a valid concern for some of these patients. Although numerous articles were found describing skin changes in COVID-19 patients, none were specifically referred to as DIHS; although there are reports of drug-induced cardiac events.[iv] These concerns underscore the reality that when looking at the skin, we must remember we are treating a patient, an individual who has complex and intricate processes occurring in the body that affects all of the systems, including the integumentary system; and all the medical disciplines have a role in identification, diagnosis, and treatment of the complications that have been reported in COVID


[i] Black J, Cuddigan J & the members of the National Pressure Injury Advisory Panel Board of Directors. 2020. Skin manifestation with COVID-19: The Purple Skin and Toes that you see may not be Deep Tissue Pressure Injury. An NPIAP White Paper. Available at Accessed May 17, 2020.

[ii] Sachdeva M, Gianott R, Shah M, Lucia B, Tosi D, Veraldi S, et al. Cutaneous manifestation of COVID-19: Report of three cases and a review of the literature. Journal of Dermatological Science. 2020. Available at Accessed May 18, 2020.

[iii] Magro C, Mulvey JJ, Berline D, Nuovo G, Salvatore S, Harp J, et al. Complement associated mircrovascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: A report of five cases. Available at Accessed May 17, 2020.

[iv] Malloy T, Mayo Clinic outlines approach for patients at risk of drug-induced sudden cardiac death in COVID-19. Accessed May 17, 2020.