Worsening Foot Wound in a 50-Year-Old Marathon Runner - Page 3 - Medscape Reference

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A mixed toe web infection is an infection of the interdigital spaces of the feet, primarily caused by a dermatophyte with a secondary bacterial superinfection. The primary fungal infection occurs because of heat or moisture exposure or occlusive footwear.

Damage to the stratum corneum by dermatophytes causes erosions and allows for bacterial invasion and the development of a secondary bacterial infection. The most common organism implicated in secondary toe web infections is P aeruginosa. Other involved organisms include mostly gram-negative species such as Escherichia coli, Proteus mirabilis, Morganella morganii, Enterobacter cloacae, Klebsiella pneumoniae, and Acinetobacter species and some gram-positive species such as Enterococcus faecalis and Staphylococcus aureus.[1,2]

Predisposing factors for mixed toe web infections include tinea pedis; hyperhidrosis; humidity; tight-fitting footwear; a history of prior treatment with antibiotics, antifungals, and topical corticosteroids; atopic dermatitis; psoriasis; and vascular disorders, including those related to diabetes and smoking.[1,3,4,5,6,7] In this case, the patient most likely acquired a primary tinea pedis infection due to occlusive footwear and moisture from marathon training, which ultimately developed into a secondary bacterial infection after a course of topical antifungals did not improve his initial tinea pedis.

Patients with mixed toe web infections frequently present with erosions and painful, pruritic, erythematous macerated plaques within the interdigital spaces. These lesions are often associated with a malodorous discharge and can extend to the plantar and/or dorsal foot with a well-demarcated border. Patients with darker skin may also present with crusting of the macerated plaques. Inspection of the toenails may reveal onychomycosis or onycholysis. Extension of the infection to the plantar aspect of the foot may limit mobility. Milder infections can present as scaling plaques.[1,2] In patients with a secondary P aeruginosa infection, green-yellow pus and green fluorescence under Wood light examination of the interdigital spaces may be noted.[8]

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