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. [27]
Another approach is to combine acetic acid with a topical antifungal, a combination producing a complete response in 8 of 10 patients with a P aeruginosa toe web infection. [28]
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. [29]
Consultations
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.
Activity
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.
Prevention
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.
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A 33-year-old man with interweb exudative patches. Courtesy of Rajendra Kapila, MD, Professor of Infectious Diseases, New Jersey Medical School.
