What is the treatment for cracking in the toe crease?

Treatment for Cracking in the Toe Crease

For cracking in the toe crease, apply topical antifungal therapy (terbinafine 1% cream once daily for 1 week or ciclopirox 0.77% twice daily for 4 weeks) as this is most likely tinea pedis (athlete's foot), which commonly presents with fissuring between the toes. 1

Initial Assessment

The most common cause of cracking in toe creases is tinea pedis (athlete's foot), a fungal infection that frequently affects the interdigital spaces and causes fissuring, particularly between the toes. 1 Other potential causes include:

• Bacterial toe-web intertrigo - presents with weeping, erosive, painful lesions that may be recurrent, often with associated eczema 2
• Hyperkeratosis with fissuring - can occur in various conditions including epidermolysis bullosa and diabetes 1

First-Line Treatment Approach

For Presumed Fungal Infection (Tinea Pedis)

Topical antifungal therapy is the primary treatment:

• Terbinafine 1% cream applied once daily for 1 week - achieves approximately 94% mycological cure rate with faster clinical resolution than other agents 1
• Ciclopirox olamine 0.77% cream or gel applied twice daily for 4 weeks - achieves approximately 60% clinical and mycological cure versus 6% for vehicle alone 1
• Clotrimazole 1% cream applied twice daily for 4 weeks - effective alternative with mycological cure rates significantly better than placebo 1, 3

Oral terbinafine 250 mg once daily for 1 week may be considered for extensive or refractory cases, with similar efficacy to 4 weeks of topical clotrimazole but faster clinical resolution. 1

For Bacterial Intertrigo

If the presentation includes weeping, erosive lesions with exudate rather than dry scaling:

• Consider Gram-negative bacterial infection (commonly Pseudomonas aeruginosa) 2
• Treatment includes topical corticosteroids combined with appropriate antimicrobial therapy 2
• Associated eczema is common (51.8% of cases) and requires concurrent management 2

Adjunctive Measures

Essential preventive and supportive care to promote healing and prevent recurrence:

• Careful and thorough drying between the toes after showers - critical for preventing moisture accumulation 1
• Daily changes of socks 1
• Foot powder application after bathing - associated with decline in tinea pedis rates from 8.5% to 2.1% over 3.5 years 1
• Periodic cleaning of athletic footwear 1
• Emollients and non-adherent dressings to protect fissured skin 1

For Diabetic Patients

More aggressive management is required due to increased risk:

• Immediate treatment of fissures by an appropriately trained healthcare professional 1
• More aggressive offloading and frequent monitoring essential due to increased risk of ulceration and delayed healing 4
• Appropriate footwear including open-backed shoes or extra-depth shoes with adequate toe box to reduce pressure 1, 4

When to Escalate Care

Refer to podiatry or dermatology if:

• No improvement after 2-3 months of appropriate topical therapy 1
• Recurrent infections despite treatment 2
• Presence of pre-ulcerative lesions (blisters, hemorrhage) requiring immediate professional treatment 1
• Suspected bacterial superinfection with weeping, erosive lesions 2

Common Pitfalls to Avoid

• Overdebridement of fissured areas can worsen blistering and tenderness, particularly in vulnerable patients - use conservative approach 1
• Corticosteroid injections near the Achilles tendon should be avoided 1
• Inadequate drying between toes is the most common preventable risk factor for recurrence 1
• Stopping treatment too early - continue for at least one week after clinical clearing of infection 3