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Mixed toe web infection - Skin
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Mixed toe web infection - Skin

Contributors: Lisa Altieri MD, Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD, MPH, Michael D. Tharp MD
Other Resources UpToDate PubMed

Synopsis

A mixed toe web infection is an infection between the toes that is caused by a primary fungal infection and worsened by secondary bacterial superinfection.

The primary event in these infections is damage to the epidermis by dermatophytes. Dermatophytes invade keratinized areas of the body, such as the skin, hair, and nails. The dermatophytes that usually cause only superficial infections of the skin are grouped into three genera: Trichophyton, Microsporum, and Epidermophyton. Damage to the stratum corneum leads to bacterial proliferation and secondary infection. The superinfection is commonly caused by the following organisms, which are present even on normal skin: Staphylococcus aureus, Staphylococcus epidermidis, aerobic diphtheroids, Enterococcus faecalis, Acinetobacter, Klebsiella, Proteus, and Pseudomonas.

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 erosion interdigitalis blastomycetica.

These infections can be disabling, with the threat of sepsis if not adequately treated.

Codes

ICD10CM:
L30.4 – Erythema intertrigo

SNOMEDCT:
402933000 – Gram-negative infection of toe web

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Interdigital tinea pedis – This is the underlying factor that causes a mixed toe web infection. There are two types: the interdigital dry type and the interdigital macerated type, which is also called a mixed toe web infection.
  • Pitted keratolysis – Shallow, rounded 1-3 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 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.
Less common:

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Therapy

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References

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Last Updated:02/11/2014
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Mixed toe web infection - Skin
Mixed toe web infection : Macerated skin, Web spaces of toes, White scaly plaque, Pruritus
Clinical image of Mixed toe web infection
Macerated scale in the third and fourth webspaces that extends to the base of the fourth toe, with surrounding hyperkeratotic scale.
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