Mixed toe web infection in Adult
The primary event in these infections is damage to the stratum corneum by dermatophytes. This is superseded by bacterial proliferation and secondary infection. The superinfection is commonly caused by the organisms, which are present even on normal skin, such as Staphylococcus aureus, Staphylococcus epidermidis, aerobic diphtheroids, Enterococcus faecalis, Acinetobacter, Klebsiella, Proteus, and Pseudomonas. Pseudomonas is the most commonly identified organism in gram-negative toe web infection, either alone or within a mixed gram-negative infection.
Bacteria and fungi are more likely to grow in warm, moist environments. Therefore, hot weather, excess sweating, athletic / recreational activities, and closed-toe / tight-fitting shoes can lead to mixed toe web infections, which can appear similar to Candida toe web infections, known as erosio interdigitalis blastomycetica.
Diabetes and smoking are predisposing risk factors for the development of mixed toe web infections.
These infections can be disabling, with the threat of cellulitis or septicemia in immunocompromised individuals, if not adequately treated.
B96.89 – Other specified bacterial agents as the cause of diseases classified elsewhere
402933000 – Gram-negative infection of toe web
Differential Diagnosis & Pitfalls
- Interdigital tinea pedis – This is the underlying factor that causes a mixed toe web infection. There are 2 types: the interdigital dry type and the interdigital macerated type, which is also called a mixed toe web infection.
- Pitted keratolysis – Shallow, rounded, 1- to 3-mm pits present on the pressure-bearing areas of the soles; lesions can coalesce to form furrows, and affected areas may become macerated.
- Atopic dermatitis – Usually favors the first and second web spaces.
- Candidiasis – The maceration induced by Candida albicans is less severe than that caused by gram-negative bacteria. Associated with poorly controlled diabetes mellitus. Antifungal therapy alone will result in complete remission. The severe form is known as erosion interdigitalis blastomycetica.
- Psoriasis – Sometimes psoriasis may be limited to the soles or may present in a palmoplantar distribution.
- Erythrasma – Brown, minimally scaly plaques with sharp borders. Web space erythrasma is typically hyperkeratotic but can be erosive.
- Contact dermatitis
- Dyshidrotic eczema – Presents with pruritus, scale, and deep-seated pinpoint vesicles on the palms, soles, and lateral digits.
- Acrodermatitis continua of Hallopeau
- Secondary syphilis – Condyloma lata can be seen between the toes and may be a patient's only manifestation of secondary syphilis.