The underrepresentation of “COVID toes” in skin of color: An example of racial bias or evidence of a tenuous disease association?

Under‐representation of people of African ancestry in publications on the cutaneous manifestations of COVID‐19: coincidence or physiology?

“…This was consistent with previous studies reporting this rate between 70 and 97%. [3][4][5] Of note, this rate was staggeringly higher than what was reported before this pandemic (20-50%). 6 The most commonly affected site was nose (76%) followed by cheeks (61.1%), hands (49.8%), chin (8.1%) and neck (4.4%).…”

“…1 Indeed, very few patients of non-European descent were reported among 318 cases of COVID-19-related perniosis 2 and there was a virtual absence of 'Covid toes' among a large population of African-American and Hispanic patients during the COVID-19 outbreak in New York City. 3 These results prompted us to review the clinical charts and photographs of 80 patients referred by general practitioner, private practice dermatologists or emergency services to our department for chilblain-like lesions during the first wave of COVID-19 outbreak in Paris, between 9 April and 16 April 2020. None of the patients were of sub-Saharan African descent or had Fitzpatrick's skin phototype of 5 or 6.…”

Viral exanthema in the Americas during the SARS‐CoV‐2 pandemic infection: dengue or COVID‐19?

“…Otherwise, the underrepresentation of Afro‐Caribbeans in this series may possibly be due to the lower visibility of exanthema in skin of color. If not, it raises the controversial question of the low frequency of such viral manifestations in this ethnicity 5 …”

Coronavirus Disease 2019 and Race in Dermatology

“… 29 Similarly, other vascular cutaneous manifestations, such as chilblain-like lesions, vasculitis, and vasculopathic ulcers, were rarely reported among Indian patients. 30 If not just due to reporting bias, 31 , 32 some pathophysiologic mechanisms that have been proposed are that increased levels of lipoprotein A in some populations could predispose patients to cardiovascular and peripheral arterial diseases or that Factor V Leiden in white populations compared with Asian populations could explain the differences in thromboembolic events. 29 …”

“… 31 However, additional literature notes that COVID-toes manifestations are uncommon in pigmented skin. 32 It is not yet clear if this paucity of COVID toes in skin of color is due to underrecognition by patients and providers of this phenomenon in darker skin, less access to health care, or truly less incidence of pernio/chilblains/COVID toes in some populations, or a multifactorial combination of all of these.…”