Esther Ellen Freeman, MD, PhD: How COVID-19 Is Affecting Skin Differently in 2023


Symptoms including vestibular rashes and COVID toes have become less synonymous with SARS-CoV-2 infection. Why is that?

It may be hard to remember, but there was a time during the early months of the COVID-19 pandemic when the virus was as present in the skin as it was in nearly any systemic symptom. Reports of urticaria, thromboembolic cutaneous changes and the infamous “COVID toes” were frequent and, per one expert, often synonymous with a positive SARS-CoV-2 test.

In 2023, COVID-19 is just as present an infection threat—but its impact in skin has dulled.

In an interview with HCPLive leading up to the American Academy of Dermatology (AAD) 2023 Annual Meeting in New Orleans this weekend, Esther Ellen Freeman, MD, PhD, associate professor of dermatology at Harvard Medical School, reflected on the evolving nature of COVID-19 dermatologic manifestations. The change in skin manifestation has been in line with 3 factors, Freeman explained: the widespread availability of vaccines and boosters, the evolution and mutation of the virus, and the diminishing likelihood of a newly infected person seeking immediate care for symptoms.

“People who experienced Omicron may have perceived it as a sore throat, and cough has definitely become less frequent as a main sign of COVID-19,” Freeman explained. “And along with these changes that we’re seeing in symptoms of other organ symptoms, we’re seeing this with skin.”

Despite there being about 30 known skin manifestations of COVID-19, there are fewer and fewer present in current iterations of disease. Freeman reflected on the once-controversial subject of COVID toes frequency and how it associated with positive cases.

“I’m of the camp that we do have a lot of significant data about interferon response…and it does look like early on in the pandemic with the earlier variants, including up through Delta, that having a rash on the toes or feet was actually statistically predictive of a positive SARS-CoV-2 test,” Freeman said. “Interestingly, when we got to Omicron, that no longer holds true.”

Freeman also discussed the history of epidemics and pandemics as to how skin manifestations presented. History is inconclusive on whether this trend of dwindling skin symptoms is consistent in previous outbreaks, she explained.

“I think COVID-19 is a bit unique in the number of skin manifestations it causes,” Freeman said. “If you look at COVID-19 at all, what other virus can we think of that will kill one person, then in the next person they’re just like, ‘Huh, my Diet Coke tastes funny’.”

It’s a very similar wide spectrum of severity when it comes to skin manifestations.

One thing that is known from history, however, is that dermatology has often been prevalent in disease diagnosis from the greatest outbreaks—including the plague.

“I don’t think we’re necessarily seeing this attenuation of effect that we’ve seen in other viruses over time, but do I think that dermatologists have very frequently had a role in identifying different outbreaks and pandemics? Absolutely,” Freeman said.

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