Gram-Negative Toe Web Infection Clinical Presentation

Updated: Mar 26, 2021
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: William D James, MD  more...
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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. [10] 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.


Physical Examination

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.



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. [11] 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. [12]

A Pseudomonas toe web infection may be complicated by an autosensitization dermatitis. [13]