What is the treatment for webspace intertrigo or infection between the toes?

Treatment of Webspace Intertrigo/Infection Between Toes

For webspace intertrigo between the toes, topical antifungal agents (clotrimazole, miconazole, or nystatin) combined with keeping the area dry are the first-line treatments, with oral terbinafine 250 mg daily for 2 weeks reserved for severe, extensive, or treatment-resistant cases. 1, 2

Initial Management Approach

Moisture Control and Environmental Modifications

• Keep the infected area dry as the most critical intervention 1
• Apply absorbent powders (cornstarch) or barrier creams to minimize moisture and friction 3
• Wear light, nonconstricting, absorbent clothing; avoid wool and synthetic fibers 3
• Wear open-toed shoes specifically for toe web intertrigo 3
• Thoroughly dry between toes after showering, change socks daily, and clean athletic footwear periodically 2

Topical Antifungal Therapy (First-Line)

• Topical azoles (clotrimazole, miconazole) or polyenes (nystatin) are effective for candidal skin infections and intertrigo 1
• For dermatophyte intertrigo, topical terbinafine, azoles, or tolnaftate are appropriate 4
• Apply twice daily (morning and night) for 1 week for infections between the toes 5
• Topical terbinafine cures most athlete's foot and relieves itching, burning, cracking, and scaling 5

When to Escalate to Systemic Therapy

Indications for Oral Antifungals

• Severe or extensive disease 2
• Failed topical therapy 2
• Moccasin-type or vesiculobullous forms 2
• Concomitant onychomycosis requiring longer systemic therapy 2
• Immunocompromised or diabetic patients 2

Oral Treatment Regimen

• Oral terbinafine 250 mg once daily for 2 weeks is the most effective first-line systemic treatment for aggressive foot fungus 2
• Terbinafine has superior efficacy against dermatophytes with over 70% oral absorption and fungicidal action 2
• Alternative: Itraconazole with flexible dosing, though slightly lower efficacy and potentially higher relapse rates 2
• Terbinafine is preferred over itraconazole in diabetic patients due to lower risk of drug interactions and hypoglycemia 2

Monitoring Requirements

• Baseline liver function tests and complete blood count for terbinafine in patients with history of hepatotoxicity or hematological abnormalities 2

Special Considerations for Bacterial Superinfection

Gram-Negative Bacterial Intertrigo

• Gram-negative bacterial toe-web intertrigo presents with weeping, erosive, painful lesions that may be recurrent 6
• Pseudomonas aeruginosa is the predominant pathogen (48.1% of cases) 6
• Eczema is frequently associated (51.8% of cases) and should be treated concurrently 6
• Risk factors include psoriasis, local humidity, fungal intertrigo, vascular disease, and history of multiple local treatments 6
• Secondary bacterial infections should be treated with antiseptics or antibiotics depending on the pathogen 3

Cellulitis Complicating Toe Web Infection

• In lower-extremity cellulitis, carefully examine interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce recurrence 1
• The responsible streptococci are frequently present in macerated or fissured interdigital toe spaces 1
• Treating toe web abnormalities is essential for preventing recurrent cellulitis 1

Prevention of Recurrence

Environmental Decontamination

• Discard old, contaminated footwear or decontaminate by placing naphthalene mothballs in shoes, sealing in plastic bags for minimum 3 days 2
• Apply antifungal powders containing miconazole, clotrimazole, or tolnaftate in shoes and on feet 1
• Spray terbinafine solution into shoes periodically 1

Ongoing Preventive Measures

• Apply foot powder after bathing 2
• Wear cotton, absorbent socks 1
• Always wear protective footwear in public bathing facilities, gyms, and hotel rooms 1
• Shower after physical exercise and dry intertriginous areas thoroughly 3

Treating Predisposing Factors

• Identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities 1
• Patients should be encouraged to lose weight and receive proper endocrinologic treatment for diabetes 7
• Treat all infected family members simultaneously as both onychomycosis and tinea pedis are contagious 1

Common Pitfalls to Avoid

• Inadequate treatment duration leads to recurrence; failing to extend treatment in severe cases is a common error 2
• Overlooking concomitant onychomycosis, which requires longer systemic therapy 2
• Griseofulvin is not recommended as first-line therapy due to lower efficacy, longer treatment duration, and greater drug interactions 2
• Failing to address moisture control and environmental factors will result in treatment failure regardless of antimicrobial choice 1, 3
• Not examining for and treating other superficial infection sites or investigating sources of reinfection 4