Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Gram-Negative Toe Web Infection Differential Diagnoses

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

Diagnostic Considerations

Group A beta-hemolytic streptococci may produce a variety of common childhood cutaneous infections.[6] It is typically seen as intense, fiery red erythema and maceration in the intertriginous folds of the neck, axillae, or inguinal spaces, and has a distinctive foul odor. It should also be contemplated in the differential diagnosis of interweb toe infections.

Fungal interdigital tinea pedis should also be considered.[7] Fusarium solani infection may be the nondermatophytic filamentous fungi responsible. Bilateral intertrigo of the third and fourth interdigital spaces of the feet due to a Fusarium solani infection in an immunocompetent Senegalese man has been described.[8] Infection with this mold is potentially dangerous for the immunosuppressed.

Diabetic patients with ischemic foot ulcers differ with neuropathic foot ulcer patients in having a higher frequency of S epidermidis skin colonization and ulcer infection. S epidermidis may be a nosocomial pathogen.[9] The relationship of each other type to interweb infections remains to be determined.

Trichophyton tonsurans tinea gladiatorum is an emerging epidemic among combat-sport athletes, which may involve scalp, trunk, groin, and toe web spaces.[10]

Itchy maceration of the toe webs is a common disorder often confused with tinea. Bacterial cultures often grow mixed pathogens (93%). Pseudomonas aeruginosa, Enterococcus faecalis, and Staphylococcus aureus were the most common pathogens in one study.[11]

In addition, dermatophytids, which result from sensitization to a dermatophyte infection, may be associated with toe web intertrigo.[12]

Interdigital intertrigo and onychomycosis may result in severe bacterial infection with complications including pain, mobility problems, abscess, erysipelas, cellulitis, fasciitis, and osteomyelitis.[13, 14] Dermatophytic infections in interdigital spaces damage the stratum corneum, leading to bacterial proliferation and secondary infection. Although toe web intertrigo temporarily disrupts the skin barrier and is a risk factor for erysipelas, it may not predispose to repeated episodes of erysipelas.[15] Another study found a significant association between interdigital tinea pedis and the recurrence rate of erysipelas, but not with erysipelas itself.[16]

The interdigital bacterial infection erythrasma, caused by Corynebacterium minutissimum, should also be considered.[17, 18] Wood-lamp examination is a good idea, but it may not identify all of those infected with this gram-positive rod.

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

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.

Acknowledgements

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.

References
  1. Aste N, Atzori L, Zucca M, Pau M, Biggio P. Gram-negative bacterial toe web infection: a survey of 123 cases from the district of Cagliari, Italy. J Am Acad Dermatol. 2001 Oct. 45(4):537-41. [Medline].

  2. Karaca S, Kulac M, Cetinkaya Z, Demirel R. Etiology of foot intertrigo in the District of Afyonkarahisar, Turkey: a bacteriologic and mycologic study. J Am Podiatr Med Assoc. 2008 Jan-Feb. 98(1):42-4. [Medline].

  3. Leyden JJ. Progression of interdigital infections from simplex to complex. J Am Acad Dermatol. 1993 May. 28(5 Pt 1):S7-S11. [Medline].

  4. Vento TJ, Cole DW, Mende K, Calvano TP, Rini EA, Tully CC, et al. Multidrug-resistant gram-negative bacteria colonization of healthy US military personnel in the US and Afghanistan. BMC Infect Dis. 2013 Feb 5. 13:68. [Medline]. [Full Text].

  5. Mokni M, Dupuy A, Denguezli M. Risk factors for erysipelas of the leg in Tunisia: a multicenter case-control study. Dermatology. 2006. 212(2):108-12. [Medline].

  6. Honig PJ, Frieden IJ, Kim HJ, Yan AC. Streptococcal intertrigo: an underrecognized condition in children. Pediatrics. 2003 Dec. 112(6 Pt 1):1427-9. [Medline].

  7. Diongue K, Ndiaye M, Diallo MA, Seck MC, Badiane AS, Diop A, et al. Fungal interdigital tinea pedis in Dakar (Senegal). J Mycol Med. 2016 May 12. [Medline].

  8. Romano C, Presenti L, Massai L. Interdigital intertrigo of the feet due to therapy-resistant Fusarium solani. Dermatology. 1999. 199(2):177-9. [Medline].

  9. Galkowska H, Podbielska A, Olszewski WL, Stelmach E, Luczak M, Rosinski G, et al. Epidemiology and prevalence of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis in patients with diabetic foot ulcers: focus on the differences between species isolated from individuals with ischemic vs. neuropathic foot ulcers. Diabetes Res Clin Pract. 2009 May. 84(2):187-93. [Medline].

  10. Ilkit M, Gumral R, Saracli MA, Burgut R. Trichophyton tonsurans scalp carriage among wrestlers in a national competition in Turkey. Mycopathologia. 2011 Apr 7. [Medline].

  11. Lin JY, Shih YL, Ho HC. Foot bacterial intertrigo mimicking interdigital tinea pedis. Chang Gung Med J. 2011 Jan-Feb. 34(1):44-9. [Medline].

  12. Ronjat L, Ferneiny M, Hadj-Rabia S, Boccara O, Bodemer C. [Generalized exanthematous pustular dermatophytid, a rare clinical presentation of dermatophytid reaction]. Ann Dermatol Venereol. 2015 Apr. 142 (4):270-5. [Medline].

  13. Vanhooteghem O, Szepetiuk G, Paurobally D, Heureux F. Chronic interdigital dermatophytic infection: A common lesion associated with potentially severe consequences. Diabetes Res Clin Pract. 2011 Jan. 91(1):23-5. [Medline].

  14. Aragón-Sánchez J, Lipsky BA, Lázaro-Martínez JL. Gram-negative diabetic foot osteomyelitis: risk factors and clinical presentation. Int J Low Extrem Wounds. 2013 Mar. 12(1):63-8. [Medline].

  15. Inghammar M, Rasmussen M, Linder A. Recurrent erysipelas--risk factors and clinical presentation. BMC Infect Dis. 2014 May 18. 14:270. [Medline]. [Full Text].

  16. Müller DP, Hoffmann R, Welzel J. Microorganisms of the toe web and their importance for erysipelas of the leg. J Dtsch Dermatol Ges. 2014 Aug. 12(8):691-5. [Medline].

  17. Inci M, Serarslan G, Ozer B, Inan MU, Evirgen O, Erkaslan Alagoz G, et al. The prevalence of interdigital erythrasma in southern region of Turkey. J Eur Acad Dermatol Venereol. 2011 Oct 7. [Medline].

  18. Ramírez-Hobak L, Moreno-Coutiño G, Arenas-Guzmán R, Gorzelewski A, Fernández-Martínez R. [Treatment of interdigital foot Erythrasma with ozonated olive oil]. Rev Med Inst Mex Seguro Soc. 2016 Jul-Aug. 54 (4):458-61. [Medline].

  19. Kates SG, Myung KB, McGinley KJ, Leyden JJ. The antibacterial efficacy of econazole nitrate in interdigital toe web infections. J Am Acad Dermatol. 1990 Apr. 22(4):583-6. [Medline].

  20. King DF, King LA. Importance of debridement in the treatment of gram-negative bacterial toe web infection. J Am Acad Dermatol. 1986 Feb. 14(2 Pt 1):278-9. [Medline].

  21. Day MR, Day RD, Harkless LB. Cellulitis secondary to web space dermatophytosis. Clin Podiatr Med Surg. 1996 Oct. 13(4):759-66. [Medline].

  22. Siljander T, Karppelin M, Vähäkuopus S, Syrjänen J, Toropainen M, Kere J, et al. Acute bacterial, nonnecrotizing cellulitis in Finland: microbiological findings. Clin Infect Dis. 2008 Mar 15. 46(6):855-61. [Medline].

  23. Borelli C, Korting HC, Bödeker RH, Neumeister C. Safety and efficacy of sertaconazole nitrate cream 2% in the treatment of tinea pedis interdigitalis: a subgroup analysis. Cutis. 2010 Feb. 85(2):107-11. [Medline].

  24. Bjornsdottir S, Gottfredsson M, Thorisdottir AS, Gunnarsson GB, Ríkardsdottir H, Kristjansson M, et al. Risk factors for acute cellulitis of the lower limb: a prospective case-control study. Clin Infect Dis. 2005 Nov 15. 41(10):1416-22. [Medline].

  25. Janniger CK, Schwartz RA, Szepietowski JC, Reich A. Intertrigo and common secondary skin infections. Am Fam Physician. 2005 Sep 1. 72(5):833-8. [Medline].

 
Previous
Next
 
A 33-year-old man with interweb exudative patches. Courtesy of Rajendra Kapila, MD, Professor of Infectious Diseases, New Jersey Medical School.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.