The most important step in the treatment of interdigital maceration is to dry the area thoroughly. This can be done by wiping the area gently with a towel or, for patients with limited mobility, using methylated spirits on a cotton pad. Insufficient drying will lead to recurrence of the condition and can delay the start of antimicrobial therapy. It is also important to recognize that a mixed infection of dermatophyte and bacterial colonization may be present.
Antimicrobial Therapy
Often, antifungal agents will be effective, however in cases of persistent recurrent cellulitis, it is important to consider the possibility of opportunistic bacterial co-infection. PCR analysis has shown that 45% of dermatophyte-positive specimens have a concomitant bacterial infection 5.
GNTWI is characterized by erythema, vesiculopustules, maceration, and malodorous exudate of the skin of the interdigital spaces of the feet and metatarsal pads and can be complicated by the development of a systemic reaction 6. The foot flora that is normally colonised by coagulase-negative staphylococci, micrococci, coryneform organisms and gram-negative bacteria including P. aeruginosa which is responsible for lethal hospital-acquired infections in immunocompromised individuals 7. In our case, the patient had a history of previous unsuccessful treatment with topical and oral antifungal agents. The presence of beefy-red denuded maceration with a well demarcated punch-out edge at the digitoplantar sulcus and toe web is pathognomonic of GNTWI. Correct diagnosis is essential as each attack of GNTWI causes lymphatic inflammation which may lead to permanent damage to the soft tissue if left untreated 8. Correct management will result in prompt resolution and the prevention of further infection.
Prevention of Recurrence
To avoid recurrence of the condition, patients should ensure that the area between their toes is dry. This can be done by wiping with a towel after showering, using methylated spirits in a spray bottle for those with limited mobility (to help reach the toes), and wearing breathable shoes and socks. It is important to remember that the skin between the toes can become macerated due to both fungal infection and bacterial colonization. Therefore, a comprehensive treatment plan is needed to address both conditions and reduce the risk of recurrence.
Chronic intertriginous tinea pedis, also known as “tinea pedis,” is a common problem caused by the fungus Trichophyton mentagrophytes. This condition can cause a white, soggy appearance to the skin between the toes and is typically itchy and painful. It can progress to vesiculobullous tinea pedis, in which the toe web lesions coalesce into vesicles that may ooze or exude. In these cases, secondary bacterial infection and cellulitis may occur.
A 53-year-old male presented to our clinic with a 10-month history of malodorous maceration involving the toe webs and metatarsal pads of both feet. He had a history of prior unsuccessful treatment with topical and oral antifungal agents. Physical examination revealed beefy-red, denuded maceration with a well-demarcated punch-out edge at the interdigital spaces of the feet and metatarsal pads that were bordered by peripheral erythema and a fruity-smelling exudate.