Use of 20% Aluminum Chloride for Bacterial Overgrowth in Wet Macerated Athlete's Foot
Yes, 20% aluminum chloride solution is an effective and appropriate treatment for bacterial overgrowth associated with wet, macerated athlete's foot, as it provides both antimicrobial activity and chemical drying to address the underlying pathophysiology.
Understanding the Pathophysiology
The wet, macerated presentation of athlete's foot represents a complex infection pattern where fungal invasion creates conditions that promote secondary bacterial overgrowth 1:
- Dermatophytes initiate the infection by invading the horny layer of interdigital skin 1
- Moisture accumulation from sweating, exercise, or occlusive footwear stimulates bacterial proliferation 1
- Aerobic diphtheroids cause the common wet, macerated presentation, while Gram-negative organisms (Pseudomonas, Proteus) produce more severe cases 1
- Macerated ulcers from soaking are particularly associated with Pseudomonas aeruginosa, often in polymicrobial combinations 2
Why Aluminum Chloride Works
Aluminum chloride addresses both components of this infection through a dual mechanism 1, 3:
- Broad-spectrum antimicrobial activity against bacteria and fungi, rapidly controlling odor, pruritus, and maceration 3
- Chemical drying (astringency) through protein binding, which is the decisive therapeutic element 1, 3
- 30% aluminum chloride solution was found equivalent to carbol-fuchsin solution (Castellani paint) in clinical trials 3
- 20% concentration provides effective antimicrobial and drying effects with better tolerability 3
The beneficial effect depends primarily on drying the surface rather than killing organisms, making it ideal for the wet, macerated presentation 3.
Treatment Algorithm
Immediate Management
- Apply 20% aluminum chloride solution to affected interdigital spaces once or twice daily 1, 3
- Maximize air exposure by wearing sandals when possible to enhance evaporation 1
- Keep feet dry between applications 4
Concurrent Antifungal Therapy
- Add topical terbinafine 1% cream twice daily for 1 week to address the underlying dermatophyte infection 5
- Aluminum chloride controls bacterial overgrowth and maceration while antifungals treat the fungal component 1
For Severe or Resistant Cases
- Consider oral terbinafine 250 mg daily for 1-2 weeks if topical therapy fails 5, 6
- Obtain fungal cultures before switching therapy to verify treatment failure 6
- Check for Pseudomonas if Gram-negative infection is suspected, as this may require additional antibiotic coverage 2
Essential Adjunctive Measures
Prevention of recurrence requires addressing moisture and reinfection sources 5, 6:
- Change socks daily and use absorbent cotton socks 4
- Apply foot powder after bathing (reduces recurrence from 8.5% to 2.1%) 5, 6
- Clean athletic footwear periodically to eliminate contaminated reservoirs 5, 6
- Treat concomitant onychomycosis, as nail infection serves as a reservoir for reinfection 6
- Examine and treat all infected family members simultaneously to prevent reinfection 6
- Wear sandals in communal showers and locker rooms 4, 7
Critical Pitfalls to Avoid
- Do not use aluminum chloride alone without addressing the underlying fungal infection—suppression of bacteria is essential but fungal treatment prevents recurrence 1
- Do not assume permanent eradication is possible—the presence of infection in nails or soles ensures reinfection risk 1
- Do not overlook Gram-negative organisms in severe macerated cases, which may require broader antimicrobial coverage 2
- Do not neglect footwear as a contamination source—failure to address this leads to treatment failure 6
Special Considerations
- Diabetic patients with macerated interdigital spaces require particular attention, as these fissures serve as portals for streptococcal cellulitis 2
- Athletes in communal settings need aggressive prevention strategies including daily sock changes and shower sandals 2
- Seasonal flare-ups are common in summer and can be prevented with prophylactic drying measures 1