History

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.

Complications

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]

Differential Diagnoses

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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. [QxMD MEDLINE Link].
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Leyden JJ. Progression of interdigital infections from simplex to complex. J Am Acad Dermatol. 1993 May. 28(5 Pt 1):S7-S11. [QxMD MEDLINE Link].
Hay RJ. Gram Negative Toe Web Infection - A Not So Rare but Neglected Syndrome. Acta Derm Venereol. 2019 Oct 30. 99 (12):1070. [QxMD MEDLINE Link].
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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. [QxMD MEDLINE Link].
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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. [QxMD MEDLINE Link].
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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. [QxMD MEDLINE Link].
Ilkit M, Gumral R, Saracli MA, Burgut R. Trichophyton tonsurans scalp carriage among wrestlers in a national competition in Turkey. Mycopathologia. 2011 Apr 7. [QxMD MEDLINE Link].
Lin JY, Shih YL, Ho HC. Foot bacterial intertrigo mimicking interdigital tinea pedis. Chang Gung Med J. 2011 Jan-Feb. 34(1):44-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Inghammar M, Rasmussen M, Linder A. Recurrent erysipelas--risk factors and clinical presentation. BMC Infect Dis. 2014 May 18. 14:270. [QxMD MEDLINE Link]. [Full Text].
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Media Gallery

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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Author

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Professor of Pediatrics, Professor of Medicine, Rutgers New Jersey Medical School

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, New York Academy of Medicine, Royal College of Physicians of Edinburgh, Sigma Xi, The Scientific Research Honor Society

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Former 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: Alpha Omega Alpha, American Academy of Dermatology, Association of Military Dermatologists, Phi Beta Kappa, Texas Dermatological Society

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: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

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.