What is the treatment for a toe web infection?

Treatment for Toe Web Infection

The treatment for toe web infection requires both antifungal and antibacterial therapy, with topical antifungals being the first-line treatment for mild infections, and oral antibiotics added for moderate to severe or erosive infections. 1

Diagnosis and Assessment

Before initiating treatment, assess the severity of the toe web infection:

• Look for maceration, fissuring, scaling, erosions, or exudates between toes
• Check for signs of secondary bacterial infection (pain, erythema, purulence)
• Determine if there is extension beyond the toe web (cellulitis)
• Identify risk factors: diabetes, occlusive footwear, hyperhidrosis, smoking 2

Treatment Algorithm

1. Mild Toe Web Infection (Primarily Fungal)

• First-line therapy: Topical antifungal treatment

  • Apply terbinafine cream twice daily for 1 week between the toes 3
  • Alternative options: clotrimazole, miconazole, or other azole antifungals

• Adjunctive measures:

  • Keep feet dry and clean
  • Wear well-fitting, ventilated shoes
  • Change shoes and socks at least once daily 3
  • Carefully examine and treat all interdigital toe spaces 1

2. Moderate to Severe Toe Web Infection (With Bacterial Component)

• For erosive or exudative lesions:

  • Continue topical antifungal treatment
  • Add topical antibacterial agents (e.g., Castellani's paint) 4
  • Consider topical corticosteroids if significant inflammation or eczematous changes are present 5

• For infections with signs of cellulitis:

  • Oral antibiotics active against streptococci (primary pathogen)
  • Options include dicloxacillin, cephalexin, clindamycin, or erythromycin 1
  • Duration: 5 days is typically sufficient for uncomplicated cases 1

3. Chronic or Recurrent Infections

• For persistent fungal component:

  • Consider oral antifungal therapy
  • Terbinafine is more effective than griseofulvin (RR 2.26,95% CI 1.49 to 3.44) 6
  • Typical duration: 1-2 weeks for terbinafine

• For gram-negative bacterial infections:

  • Ciprofloxacin or other fluoroquinolones may be needed, especially for Pseudomonas infections 4
  • Culture and susceptibility testing should guide antibiotic selection

Special Considerations

• Diabetic patients require more aggressive treatment due to higher risk of complications 1
• Gram-negative bacterial toe web infections are often underrecognized but should be suspected in cases with:
  • Maceration with vesiculopustules and hyperkeratotic rim
  • Failure to respond to standard antifungal therapy
  • Pseudomonas (most common pathogen in 48.1% of cases) may be detected with Wood's lamp examination (fluorescence) 5, 4

Prevention of Recurrence

• Treat all family members with tinea pedis
• Disinfect shoes and avoid sharing personal items
• Address predisposing factors:
  • Manage hyperhidrosis
  • Avoid occlusive footwear, especially in high-risk occupations 2, 7
  • Treat underlying conditions like diabetes
  • Consider smoking cessation (71.2% of patients with toe web infections are smokers) 2

Common Pitfalls

1. Failing to recognize and treat the underlying fungal infection, which often predisposes to bacterial superinfection
2. Not addressing both fungal and bacterial components in mixed infections
3. Discontinuing treatment prematurely before complete resolution
4. Neglecting preventive measures, leading to recurrence (33% of patients experience recurrent infections) 2
5. Missing gram-negative bacterial infections, which require specific antibiotic therapy

Early and appropriate treatment of toe web infections is crucial to prevent progression to cellulitis and more serious complications, especially in patients with diabetes or vascular disease.