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


Gram-Negative Toe Web Infection Treatment & Management

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

Medical Care

In a 1972 study describing gram-negative toe infection, the authors found no single or simple therapeutic agent to be regularly effective as a quick cure. Patients with positive fungal culture results were treated with bedrest and supportive measures to prevent maceration. In severe infection, hospitalization is often required.

Drying of the interdigital web spaces eliminates the causative organisms that require high humidity for growth. Pledgets placed between the toes and a fan to circulate air are easy, inexpensive modalities.

Topical econazole nitrate therapy may be beneficial. Randomized treatment with either econazole nitrate or its vehicle was administered to 24 patients with severe interdigital toe web infections and no evidence of dermatophyte colonization. Of the patients treated with econazole nitrate, 88% had a good-to-excellent response, while no patients treated with the vehicle showed improvement. Total aerobic flora decreased 93% in the econazole group, with a decrease in the number of large-colony diphtheroids, lipophilic diphtheroids, and gram-negative bacteria. The results of this study demonstrate that the antibacterial activity of econazole nitrate makes it an effective agent for the treatment of severe interdigital bacterial infections uncomplicated by dermatophyte colonization.[19]

Another option is treatment with oral ciprofloxacin and local application of Castellani paint.

Proper identification of the gram-negative organisms is critical so that effective antibiotic therapy can be initiated. Early diagnosis, patient education and awareness of the infection, and a timely therapy all help lead to recovery in most patients.

In severe cases where systemic symptoms suggest septicemia, therapy should be initiated while awaiting blood culture results.


Surgical Care

Occasionally, if the infection is advanced, superficial debridement may allow creams, ointments, or other antibiotic agents to reach infected areas faster, promoting healing and stopping the spread of the infection into surrounding areas.[20]



If a diagnosis of sepsis is considered, an internist with advanced knowledge in infectious diseases should be consulted. Possible deep tissue infection should prompt surgical evaluation.



Patients should be educated on the importance of keeping the toe webs dry. After a shower, the feet and the areas between the toes should be thoroughly dried. Wearing an open-toed sandal or shoe can be beneficial. The risk is higher in individuals who participate in water-related activities.



This disorder can rarely progress to a life-threatening situation. Occasionally, in advanced severe cases, certain microorganisms (eg, P aeruginosa) can cause therapeutic problems in relation to antibiotic resistance and a risk of potential lethal complications. If septicemia occurs, especially in a patient who is immunocompromised, the condition may produce shock and death.

Acute bacterial cellulitis is a potentially serious, often recurrent infection. Risk factors for acute bacterial cellulitis in hospitalized patients were found to include the presence of sites of pathogen entry on toe webs.[21] Improved awareness and management of toe web intertrigo, which may harbor bacterial pathogens, may reduce the prevalence of cellulitis. This bacterial, nonnecrotizing cellulitis tends to remain localized and often is recurrent.[22]



The patient's lifestyle should be modified to help prevent recurrence of the infection. Patients who engage in water-related sports should shower afterwards and ensure that interdigital spaces are thoroughly dried to prevent creating an environment for bacterial growth. Open-toed shoes or sandals are encouraged in warm weather to allow air to circulate, which prevents perspiration between the toes that can lead to overgrowth of bacteria and can cause infection. The use of gauze pledgets between the toes helps prevent occlusion, and the use of astringent soaps reduces the number of gram-negative bacteria.

The use of rubber boots should be avoided.

The feet should be kept dry if possible. Feet that actually become wet at the workplace rather than simply perspire heavily may be at increased risk of this infection.


Long-Term Monitoring

Patients should have a follow-up visit after completing the course of therapy. Culturing may be performed to ensure that the infection has cleared. Occasionally, when the bacterial infection is resolving, a sudden recurrence and reactivation of an underlying fungal infection may occur because the bacteria can no longer suppress the fungal proliferation.

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.

  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].

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.