What is the treatment for interdigital maceration?

Treatment of Interdigital Maceration

The treatment of interdigital maceration should focus on addressing both the underlying causes and secondary infections, with careful examination and treatment of fissuring, scaling, or maceration in the toe web spaces to eradicate colonization with pathogens and reduce recurrent infections. 1

Etiology and Assessment

Interdigital maceration typically results from:

• Moisture accumulation between toes
• Fungal infections (dermatophytes, Candida)
• Bacterial overgrowth (Corynebacterium, Pseudomonas, Staphylococcus aureus)
• Contributing factors: sweating, tight footwear, poor foot hygiene

Examination should focus on:

• Presence of scaling, fissuring, or maceration
• Signs of inflammation or infection
• Coral-red fluorescence under Wood's lamp (suggests Corynebacterium/erythrasma) 2

Treatment Algorithm

Step 1: Dry the Affected Area

• Keep the interdigital spaces dry
• Expose feet to air (wearing sandals when possible)
• Use cotton or lamb's wool between toes to separate digits and absorb moisture 1

Step 2: Treat Underlying Infections

For Fungal Infections (Tinea Pedis/Dermatophytosis):

• Apply topical antifungal agents:
  • Ciclopirox 0.77% gel (especially effective for dermatophytosis complex with bacterial involvement) 3
  • Other antifungal creams/solutions (terbinafine, clotrimazole, miconazole)

For Bacterial Infections:

• Apply topical antibiotics:
  • Bacitracin (apply small amount 1-3 times daily) 4
  • Clindamycin solution
  • Erythromycin solution

For Mixed Infections (Dermatophytosis Complex):

• Use combination antifungal/antibacterial agents
• Consider aluminum chloride preparations (combines antimicrobial activity with chemical drying) 5

Step 3: Prevent Recurrence

• Daily foot hygiene with thorough drying between toes
• Change socks daily, use moisture-wicking materials
• Avoid occlusive footwear, use breathable shoes
• Treat underlying conditions (e.g., hyperhidrosis)
• Consider prophylactic antifungal powder for susceptible individuals

Special Considerations

For Severe or Recurrent Cases:

• Consider oral antifungal therapy if topical treatment fails
• Evaluate for underlying conditions that predispose to recurrence:
  • Diabetes
  • Immunosuppression
  • Peripheral vascular disease
  • Chronic venous insufficiency 1

For Erythrasma:

• If Wood's lamp examination shows coral-red fluorescence, treat with:
  • Topical erythromycin or clindamycin
  • Consider oral erythromycin for extensive cases 2

Pitfalls and Caveats

1. Misdiagnosis: Interdigital maceration can be confused with other conditions. Proper diagnosis is essential for effective treatment 2.

2. Incomplete Treatment: Failure to address both fungal and bacterial components can lead to treatment failure. The "dermatophytosis complex" (concomitant bacterial colonization with fungal infection) requires comprehensive treatment 3, 6.

3. Neglecting Underlying Causes: Each attack of cellulitis causes lymphatic inflammation and possibly permanent damage. Treating interdigital maceration is crucial to prevent recurrent cellulitis 1.

4. Inadequate Drying: Moisture is a key factor in interdigital maceration. Insufficient drying will lead to treatment failure and recurrence 5.

5. Overlooking Mixed Infections: PCR diagnosis shows that mixed infections are common (45.5% of dermatophyte-positive specimens have bacterial co-infection) 6.

By following this structured approach to treating interdigital maceration, focusing on drying, appropriate antimicrobial therapy, and prevention of recurrence, most cases can be effectively managed and complications avoided.