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Gram-Negative Toe Web Infection Clinical Presentation

  • Author: Robert A Schwartz, MD, MPH; Chief Editor: William D James, MD  more...
Updated: Jun 09, 2016


The patient usually complains of a burning sensation between the toes, often with maceration. A malodorous exudate may be evident.

Gram-negative infections may cause an inability to walk, accompanied by a profuse or purulent discharge. Edematous toes and tight interdigital spaces may be evident in the early stages of the disease. In severe occurrences, individuals may have a purulent discharge with edema and intense erythema of the surrounding tissues outside the infected area. In some patients, a green discoloration may be seen with advanced gram-negative infections.

The erythematous-desquamatous type of infection may be more chronic than the acute form, with exudative, macerating, painful inflammation that causes functional disability of the feet.

Redness and swelling, which suggests concurrent cellulitis, are occasionally present and extend up the ankles and the legs.

Although malodor may be evident, it tends to be more closely associated with dermatophytic infection than with gram-negative infections. This finding may be due to suppression of malodor-producing Brevibacterium by the gram-negative organisms.

Risk factors for erysipelas (cellulitis) of the leg were evaluated.[5] In multivariate analysis, disruption of the cutaneous barrier (ie, traumatic wound, toe-web intertrigo, excoriated leg dermatosis, plantar squamous lesions) and leg edema were found to be independently associated with erysipelas of the leg, yet no association was observed with diabetes mellitus, alcoholism, or smoking. Detecting and treating toe-web intertrigo is important in the prevention of erysipelas of the leg.



Clinical manifestations are similar for most patients. Clinical features can include erythema, vesicopustules, erosions, and marked maceration caused by abundant malodorous exudate. Marked hyperhidrosis is often noted. Hyperhidrosis creates an optimum situation for overgrowth of bacteria and gram-negative organisms.

An examination should be performed to determine if the patient has a tinea pedis foot infection; contact dermatitis; foot trauma; or other predisposing local factors, such as wearing tight-fitting shoes.



The cause of gram-negative toe web infections may be related to several factors. Overgrowth of gram-negative organisms between the toes may cause the infection. Marked hyperhidrosis may predispose to the infection.

Constant wearing of closed-toe shoes so that air does not circulate around the feet increases the likelihood of overgrowth of the microorganisms that create infections. Sporting activities, especially water-related sports, increase the likelihood of growth of the bacterial organisms.

Contributor Information and Disclosures

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Rosalie Elenitsas, MD Herman Beerman Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System

Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, American Society of Dermatopathology, Pennsylvania Academy of Dermatology

Disclosure: Received royalty from Lippincott Williams Wilkins for textbook editor.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Takeji Nishikawa, MD Emeritus Professor, Department of Dermatology, Keio University School of Medicine; Director, Samoncho Dermatology Clinic; Managing Director, The Waksman Foundation of Japan Inc

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Dr. Frantisek Vosmik, and Jarrett R. Hesselbirg, MD, to the development and writing of this article.

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A 33-year-old man with interweb exudative patches. Courtesy of Rajendra Kapila, MD, Professor of Infectious Diseases, New Jersey Medical School.
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