Gram-Negative Toe Web Infection
- Author: Robert A Schwartz, MD, MPH; Chief Editor: William D James, MD more...
Gram-negative interweb foot impetigo is a relatively common and troubling disorder. The infection is commonly associated with the use of closed-toe or tight-fitting shoes and in individuals in whom strong physical exertion plays an important role in athletic, occupational, or recreational activities.
Gram-negative mixed bacterial infection with organisms, such as Moraxella, Alcaligenes, Acinetobacter, Pseudomonas, Proteus, and Erwinia species, may represent a mild secondary infection of tinea pedis. Over time, in the setting of moisture and maceration, multiple fungal and bacterial organisms may proliferate. The process may progress to advanced stages of gram-negative infection with sepsis. Note the image below.
Typically, the interweb space is colonized by polymicrobial flora. Initially, a dermatophyte infection at this site may damage the stratum corneum and produce natural substances with antibiotic properties that alter the composition of the resident bacterial flora, encouraging the proliferation of antibiotic-resistant strains.
Gram-negative bacteria may resist the antibacterial agents and many of the commonly used therapeutic agents. In other cases, marked hyperhidrosis with cutaneous maceration, often seen in people who enjoy vigorous athletic endeavors, may predispose individuals to gram-negative bacterial toe web infection. Pseudomonas aeruginosa, often together with other gram-negative bacteria, is the most common etiologic agent.
The toe web space provides a hospitable niche for gram-negative microorganisms; infection can quickly progress from mild overgrowth of resident bacteria to an advanced, severe, gram-negative infection. Lesions that affect the interdigital spaces can occasionally extend to the planta and the backs of the toes. The most frequent complaint of patients is burning and pain, and, in severe infection, problems with walking are noted.
Gram-negative bacteria gain access to the bloodstream from foci of tissue infection or possibly from heavy colonization. Trauma, tinea pedis, or depressed host resistance, as in diabetes mellitus or HIV disease, may also predispose individuals to the infection.
A US military survey for gram-negative bacteria colonization in healthy, asymptomatic military personnel (101 in the United States and 100 in Afghanistan) showed toe web spaces colonized in 35% with non–multidrug-resistant bacteria.
Few data are available on the frequency of gram-negative toe web infections.
A limited number of cases have been reported.
Gram-negative toe web infection can affect any race.
Men appear to be more frequently affected, with a male-to-female ratio of 4:1 reported in one study.
Gram-negative toe web infection affects young and elderly persons. In one series, patients were reported to be aged 1-74 years. The disorder rarely involves infants or children.
In most patients, the prognosis is excellent. With appropriate therapy, complete recovery is usually attained.
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].
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].
Leyden JJ. Progression of interdigital infections from simplex to complex. J Am Acad Dermatol. 1993 May. 28(5 Pt 1):S7-S11. [Medline].
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].
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].
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].
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].
Romano C, Presenti L, Massai L. Interdigital intertrigo of the feet due to therapy-resistant Fusarium solani. Dermatology. 1999. 199(2):177-9. [Medline].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
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].
Day MR, Day RD, Harkless LB. Cellulitis secondary to web space dermatophytosis. Clin Podiatr Med Surg. 1996 Oct. 13(4):759-66. [Medline].
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].
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].
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].
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].