Management of Itching Toes in a Diabetic Female with Normal Toe Examination
The most likely diagnosis is a superficial fungal infection (tinea pedis), and you should obtain fungal cultures or KOH preparation before initiating antifungal therapy, while simultaneously assessing for peripheral neuropathy that may mask other pathology. 1, 2
Diagnostic Approach
Immediate Assessment Required
Screen for peripheral neuropathy using the 10-g Semmes-Weinstein monofilament test, 128-Hz tuning fork for vibration perception, and assess Achilles tendon reflexes, as diabetic neuropathy can present with pruritus and may mask more serious pathology 1
Obtain fungal specimens through skin scrapings from affected areas, particularly between the toes where fungal infections commonly manifest as pruritus that patients often mistake for "dry skin" 2, 3
Examine between all toes carefully for maceration, scaling, or fissuring that may not be apparent on cursory inspection, as interdigital tinea pedis is frequently overlooked 1
Why Fungal Infection is Most Likely
The prevalence of fungal foot infections in diabetic patients is remarkably high—ranging from 35.5% to 82.1% in recent studies—making this the most probable diagnosis for isolated pruritus with normal gross examination 3, 4. Diabetic patients with fungal infections often have subtle findings that appear as "dry skin" rather than obvious mycotic infection 3.
Critical pitfall to avoid: Fungal infections disrupt skin integrity and provide an entry point for bacterial superinfection, which can rapidly progress to diabetic foot infection and ulceration in this population 2, 4.
Risk Stratification Using IWGDF System
Classify the patient's ulceration risk to determine follow-up frequency 1:
- IWGDF Risk 0 (no neuropathy or PAD): Annual screening
- IWGDF Risk 1 (neuropathy or PAD present): Screening every 6-12 months
- IWGDF Risk 2 (neuropathy + deformity/PAD/callus): Screening every 3-6 months
- IWGDF Risk 3 (history of ulcer or amputation): Screening every 1-3 months
Treatment Algorithm
If Fungal Infection Confirmed
For interdigital tinea pedis:
- Apply topical antifungal (terbinafine, imidazole, or allylamine) twice daily for 1 week 5, 2
- For plantar/moccasin-type involvement: Apply twice daily for 2 weeks 5
Consider oral antifungal therapy if: 2
- Extensive infection (vesicobullous or moccasin-type)
- Chronic or resistant infection
- Immunosuppression or poor glycemic control (HbA1c >7%)
- Concurrent onychomycosis requiring systemic treatment
The correlation between poor glycemic control (higher HbA1c) and fungal infection prevalence is significant, so optimize diabetes management concurrently 3.
Concurrent Preventive Measures
Provide structured education on: 1
Daily foot hygiene: Wash feet daily with water <37°C, dry carefully between toes, apply emollients to dry skin but NOT between toes 1
Daily self-inspection: Examine feet daily including between toes; if unable due to visual impairment, arrange caregiver assistance 1
Proper footwear: Never walk barefoot, in socks alone, or in thin-soled slippers indoors or outdoors 1
Immediate reporting: Contact healthcare provider if increased foot temperature, blisters, cuts, or ulcers develop 1
Follow-up Timing
Schedule re-evaluation based on neuropathy assessment findings 1:
- If neuropathy absent: Annual follow-up
- If neuropathy present: Every 6-12 months minimum
- If additional risk factors identified: More frequent monitoring per IWGDF stratification
Key consideration: The finding of impaired sudomotor activity (which correlates with fungal infection in type 2 diabetes) may indicate underlying autonomic neuropathy requiring closer monitoring 3.