Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle
Last reviewed: April 2026
Quick answer: COVID toes refer to chilblain-like inflammatory lesions on the toes (and sometimes fingers) that appeared during the COVID-19 pandemic, primarily in younger patients. They present as red, purple, or blue discoloration, swelling, and sometimes painful or itchy bumps on the toes. Most cases are self-limiting and resolve within 4–12 weeks. The exact mechanism remains debated — theories include direct viral effect, type I interferon response, and microthrombus formation.
When the COVID-19 pandemic began, dermatologists and podiatrists noticed a wave of patients — many of them young, healthy, and asymptomatic or mildly ill — presenting with bright red, purple, or swollen toes that looked like frostbite. The media called them ‘COVID toes.’
Years later, COVID toes remain a documented but puzzling phenomenon. Here’s what the evidence shows about what they are, who gets them, and what to do about them.
What Are COVID Toes?
COVID toes are chilblain-like acral lesions — red, purple, or blue discolorations on the toes (and occasionally fingers) associated with SARS-CoV-2 infection. ‘Chilblains’ (pernio) is the medical term for inflammatory skin changes caused by cold exposure or abnormal vascular response to cold — and COVID toe lesions look clinically identical.
The lesions were first reported in April 2020, primarily in children and young adults. Unlike most COVID-19 complications, COVID toes often appeared in people with mild or no respiratory symptoms — sometimes as the first or only sign of COVID infection.
What Do COVID Toes Look Like?
- Color: Bright red, progressing to purple or blue (chilblain appearance). May be patchy or diffuse across the toe.
- Location: Distal toes most commonly — the tip and sides of toes 1–5. The soles and fingers can also be affected.
- Swelling: Mild to moderate puffiness of affected toes.
- Texture: Some lesions are flat (macules/patches); others are raised bumps (papules/nodules).
- Pain/itch: Ranges from asymptomatic to painful or intensely itchy.
- Blistering: In severe cases, small vesicles or superficial ulcerations.
What Causes COVID Toes?
Despite several years of research, the exact mechanism remains debated. Leading theories:
- Type I interferon response: Current leading hypothesis. An exaggerated immune interferon-alpha response causes vascular inflammation in the digits. This theory is supported by genetic studies showing COVID toe patients have gain-of-function mutations in interferon pathway genes — similar to a hereditary chilblain disorder called Aicardi-Goutières syndrome.
- Microthrombi formation: Some early studies showed microclots in dermal blood vessels of COVID toe biopsies. However, later studies found similar findings in control patients, weakening this theory.
- Direct viral cytopathic effect: SARS-CoV-2 has been identified in endothelial cells of skin biopsies in some studies — but not consistently.
- Cold-exacerbated vascular response: COVID toes appeared disproportionately during spring 2020 lockdowns when people were less physically active, less outdoors, and wearing less footwear — possibly amplifying a cold-induced pernio response.
Interestingly, multiple studies failed to detect SARS-CoV-2 by PCR in the lesions themselves, and many patients with COVID toes had negative nasopharyngeal tests — suggesting an indirect immune mechanism rather than direct viral invasion.
COVID Toes vs. Other Toe Conditions
- Frostnip/chilblains (pernio): Clinically identical — the distinction is made by history (cold exposure vs. COVID association). Idiopathic chilblains exist without COVID.
- Vasculitis: Inflammatory blood vessel disease can cause similar discoloration and lesions — requires blood work and possible biopsy.
- Raynaud’s phenomenon: Triphasic color change (white → blue → red) triggered by cold. Usually more dynamic and responsive to temperature than COVID toes.
- Peripheral artery disease: Toe discoloration from vascular insufficiency — usually in older patients with risk factors, and associated with absent pulses.
- Purpura/petechiae: Blood vessel bleeding from clotting disorders — doesn’t blanch with pressure, unlike COVID toes.
⚠️ See a podiatrist or dermatologist if COVID toes show:
- Lesions that are worsening or not improving after 6 weeks
- Ulceration or skin breakdown over the toe
- Associated systemic symptoms: joint pain, rash elsewhere, fever
- Lesions in an older patient or one with cardiovascular risk factors — needs vascular evaluation
- Lesions that don’t correspond to typical COVID toe pattern — biopsy may be needed
Treatment for COVID Toes
Most COVID toes require no specific treatment — they self-resolve in 4–12 weeks. When management is needed:
- Cold avoidance: Warm socks, heated home environment, avoiding cold water — reduces vasospastic component
- Emollient creams: Urea-based or lanolin moisturizers for dry, cracked lesions
- Topical corticosteroids: Low-to-mid potency topical steroids can reduce the inflammatory component and speed resolution in symptomatic cases
- Topical tacrolimus: For persistent cases unresponsive to steroids
- Nifedipine (oral): A calcium channel blocker that improves digital blood flow — used for severe or prolonged cases; the same medication used for refractory chilblains
- Hydroxychloroquine: Reported in case series for severe or refractory COVID toes
Key takeaway: COVID toes are reassuring in one sense: they correlate with a strong antiviral immune response and appear most often in young, healthy patients with mild COVID. They are NOT a sign of serious COVID-19 complications.
Frequently Asked Questions
Are COVID toes contagious?
The toes themselves are not contagious, but the SARS-CoV-2 infection that triggers them may be. If you develop COVID toes, follow standard COVID precautions until you know your current infection status.
Can you get COVID toes without having COVID?
Possibly — several studies noted that many patients with COVID toes tested negative for active COVID-19 by PCR. This may reflect testing at the wrong time, false negatives, or that the immune response that causes COVID toes can be triggered by other mechanisms in susceptible individuals.
Do COVID toes leave permanent damage?
In the vast majority of cases, COVID toes resolve completely without scarring or permanent vascular damage. Rare cases of persistent Raynaud’s-like sensitivity to cold have been reported after COVID toe episodes.
Are COVID toes still occurring after the main pandemic?
Yes — dermatologists and podiatrists continue to see new cases following COVID-19 infections from later variants. The incidence appears lower with Omicron variants than with the original strain or Delta.
The Bottom Line
COVID toes are a real, well-documented phenomenon linked to SARS-CoV-2 immune response, particularly in young patients. They’re alarming in appearance but typically self-limiting, resolving within 4–12 weeks. Persistent, worsening, or systemically associated lesions warrant evaluation.
Ready to Get Relief?
Same-day appointments available in Howell & Bloomfield Hills, MI
4.9★ | 1,123 Reviews | 3,000+ Surgeries
Or call: (810) 206-1402
Sources
1. Blitshteyn S, Whitelaw S. Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19. Auton Neurosci. 2021;235:102819.
2. Baeck M, et al. Chilblain-like lesions and COVID-19. J Eur Acad Dermatol Venereol. 2021;35(4):e208-e211.
3. Freeman EE, et al. The spectrum of COVID-19–associated dermatologic manifestations. J Am Acad Dermatol. 2020;83(1):57-67.
When Shoes Aren’t Enough — Dr. Tom’s Top 9 Orthotics
About 30% of patients I see for foot pain need MORE than a great shoe — they need a structured insole. Below: my complete 2026 orthotic ranking with pros, cons, and the specific patient I’d give each one to.
★ DR. TOM’S COMPLETE 2026 ORTHOTIC RANKING
9 Best Prefab Orthotics by Use Case
PowerStep, CURREX, Spenco, Vionic, and Tread Labs — every orthotic I’ve fitted to thousands of patients across both Michigan offices. Each card includes pros, cons, and the specific patient I’d give it to. Real Amazon ratings, review counts, and prices below.
Best All-Purpose Orthotic for Most Patients
Semi-rigid arch shell + dual-layer cushion + deep heel cup. The orthotic I’ve fitted to more patients than any other for 15 years. APMA-accepted. Trim-to-fit design works in athletic shoes, casual shoes, and most work boots.
✓ Pros
- Semi-rigid arch shell provides true biomechanical correction
- Deep heel cup centers the heel and reduces lateral instability
- Dual-layer cushion (top + bottom) lasts 9-12 months daily wear
- Available in 8 sizes for precise fit
- APMA-accepted and clinically validated
- APMA-accepted with superior cushioning versus rigid alternatives
✗ Cons
- Too thick for most dress shoes (use ProTech Slim instead)
- Some break-in period required (3-7 days for arch tolerance)
- Not enough correction for severe pes planus or rigid pes cavus
Dr. Tom’s Recommendation: If a patient has run-of-the-mill plantar fasciitis, mild flat feet, or arch fatigue, this is the first orthotic I try. Better value than most premium alternatives for 90% of patients, which is why it’s the first orthotic I reach for in the clinic. Sub-$50 typically.
Maximum Motion Control · Flat Feet & Severe Over-Pronation
PowerStep’s most aggressive stability orthotic. Adds a 2°-7° medial heel post on top of the standard PowerStep platform — designed specifically for flat-footed patients and severe pronators who need real corrective force.
✓ Pros
- 2°-7° medial heel post adds aggressive pronation control
- Same trusted PowerStep arch shell, more correction
- Built specifically for flat-foot biomechanics
- Excellent for posterior tibial tendon dysfunction (PTTD)
- Removable top cover for cleaning
✗ Cons
- Too aggressive for neutral-arch patients
- Needs longer break-in (10-14 days) due to stronger correction
- Adds 2-3 mm of stack height — won’t fit slim dress shoes
Dr. Tom’s Recommendation: When a patient comes in with significant flat feet AND symptoms (heel pain, arch pain, knee pain), the Original PowerStep isn’t aggressive enough. The Maxx is what gets prescribed. About 25% of my flat-footed patients end up here.
Low-Profile · Fits Dress Shoes & Narrow Casuals
3 mm slim profile with podiatrist-designed tri-planar arch technology. Engineered specifically to fit inside dress shoes, oxfords, loafers, and women’s flats without crowding the toe box. Vionic was founded by an Australian podiatrist.
✓ Pros
- 3 mm slim profile (vs 7-10 mm for standard orthotics)
- Tri-planar arch technology adds support without bulk
- Built-in deep heel cup despite slim design
- Fits dress shoes WITHOUT having to remove the factory insole
- Trim-to-fit · APMA-accepted
✗ Cons
- Less arch support than full-volume orthotics
- Top cover wears faster than thicker alternatives
- Not enough correction for severe foot deformities
Dr. Tom’s Recommendation: My default when a patient says ‘I need orthotics but I have to wear dress shoes for work.’ Slim enough to fit in oxfords and pumps without the heel sliding out. The single highest-impact change you can make for office workers with foot pain.
Built-In Metatarsal Pad · Morton’s Neuroma · Ball-of-Foot Pain
Standard Pinnacle orthotic with a built-in metatarsal pad positioned proximal to the metatarsal heads — the exact location that offloads neuromas and metatarsalgia. No need for separate met pads or pad placement guesswork.
✓ Pros
- Built-in met pad eliminates DIY pad placement errors
- Specifically designed for Morton’s neuroma + metatarsalgia
- Same trusted PowerStep arch + heel cup platform
- Top cover protects sensitive forefoot skin
- Faster relief than orthotics + add-on met pads
✗ Cons
- Met pad position is fixed (can’t fine-tune individual placement)
- Some patients with very small or very large feet need custom
- Slightly thicker than the standard Pinnacle
Dr. Tom’s Recommendation: If a patient has Morton’s neuroma, sesamoiditis, or generalized ball-of-foot pain (metatarsalgia), this saves a clinic visit and a prescription. The built-in pad placement is anatomically correct for 80% of feet. Way better than DIY met pads.
Adaptive Dynamic Arch · Athletic & Daily Wear
Currex’s flagship adaptive arch technology — the orthotic flexes with your gait instead of fighting it. Different stiffness zones along the length give you targeted support at the heel, midfoot, and forefoot. Available in three arch heights (low/medium/high).
✓ Pros
- Dynamic flex zones adapt to natural gait cycle
- Three arch heights ensure precise fit
- Lighter than rigid orthotics (no ‘heavy foot’ feel)
- Excellent for runners and athletic walkers
- European podiatric design (German engineering)
✗ Cons
- More expensive than PowerStep Original ($55-65 typically)
- Less aggressive correction than Pinnacle Maxx for severe cases
- Three arch heights means you must self-select correctly
Dr. Tom’s Recommendation: I started recommending Currex three years ago for runners who said PowerStep felt ‘too rigid.’ The dynamic flex zones respect natural gait. Best for active patients who walk 8K+ steps daily and don’t need maximum motion control.
Running-Specific · Heel Strike + Forefoot Strike Compatible
Currex’s purpose-built running orthotic. The midfoot flex zone is positioned for runner’s gait mechanics, with a flared heel cushion for heel strikers and a forefoot rocker for midfoot/forefoot strikers. Tested on 1000+ runners during product development.
✓ Pros
- Designed by German biomechanics lab specifically for runners
- Dynamic arch flexes with running gait (not static like PowerStep)
- Three arch heights (low/medium/high)
- Reduces overuse injury risk in mid-distance runners
- Lightweight (no impact on cadence)
✗ Cons
- Premium price ($60-75)
- Not aggressive enough for severe over-pronators (use Pinnacle Maxx)
- Runner-specific design = less ideal for daily walking shoes
Dr. Tom’s Recommendation: If a patient runs 20+ miles per week and has plantar fasciitis or shin splints, this is the orthotic I prescribe. The dynamic flex zones respect running biomechanics in a way that no rigid PowerStep can match. Pricier but worth it for serious runners.
Cavus Foot & High-Arch Patients
Polyurethane base with a deeper heel cup and higher arch profile than PowerStep — built for cavus (high-arched) feet that need maximum cushion and support. The 5-zone cushioning system addresses the unique pressure points of high-arch feet.
✓ Pros
- Deeper heel cup centers the heel for cavus foot stability
- Higher arch profile fills the void under high arches
- 5-zone cushioning addresses cavus foot pressure points
- Polyurethane base lasts 12+ months
- Available in Wide width
✗ Cons
- Too tall/aggressive for normal or low arches
- Won’t fit slim dress shoes
- Pricier than PowerStep Original
- Some patients find the arch height uncomfortable initially
Dr. Tom’s Recommendation: Cavus foot patients are often misdiagnosed and given low-arch orthotics — that makes everything worse. Spenco’s Total Support has the arch profile that high-arch feet actually need. About 15% of my patients have cavus feet; this is what they wear.
Cushion Layer · Standing All Day · Gel Pressure Relief
NOT a true biomechanical orthotic — this is a cushion insole. But for patients who want gel pressure relief instead of arch correction (or to add ON TOP of factory insoles in work boots), this is the best gel option on Amazon.
✓ Pros
- Genuine gel cushioning (not foam pretending to be gel)
- Targeted gel waves under heel and ball of foot
- Trim-to-fit · works in most shoe types
- Sub-$15 price (most affordable option in this list)
- Massaging texture is genuinely soothing
✗ Cons
- ZERO arch support — this is cushion only
- Won’t fix plantar fasciitis or flat-foot issues
- Compresses faster than PowerStep (4-6 months)
- Top cover wears through in high-mileage applications
Dr. Tom’s Recommendation: I recommend these to patients who tell me ‘I just want my feet to stop hurting at the end of my shift’ and who don’t have a biomechanical issue. Construction workers, factory workers, retail. Pure cushion does the job for them.
Tight-Fitting Shoes · Cycling Shoes · Hockey Skates
Tread Labs Pace insole with firm orthotic arch support for flat feet and plantar fasciitis relief. The replaceable top cover design makes it one of the most durable picks in this guide — backed by a million-mile guarantee and recommended for tight-fitting athletic footwear.
✓ Pros
- Firm orthotic arch support shell (podiatrist-grade)
- Slim profile fits tight athletic footwear
- Lasts 12+ months daily wear
- Excellent for cycling shoes specifically
- Built-in odor-control treatment
✗ Cons
- Premium price ($45-55)
- Less cushion than PowerStep equivalents
- Not as aggressive correction as Pinnacle Maxx for flat feet
- The signature ‘heel cup feel’ takes 1-2 weeks to adapt to
Dr. Tom’s Recommendation: If you’re a cyclist with foot numbness, hot spots, or knee pain — this is the orthotic. The stabilizer cap solves cycling-specific biomechanical issues that no other orthotic addresses. Worth the premium for athletes.
None of these solving your foot pain?
Some patients (about 30%) need custom-molded prescription orthotics. We make 3D-scanned custom orthotics in our Howell and Bloomfield Hills offices — specifically built for your foot mechanics.
Schedule a Custom Orthotic Fitting →FSA/HSA eligible · Most insurance accepted · (810) 206-1402
Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.
- Plantar Fasciitis: Diagnosis and Conservative Management (PubMed)
- Plantar Fasciitis (APMA)
- Diagnosis and Treatment of Plantar Fasciitis (PubMed / AAFP)
- Heel Pain (APMA)