What is the appropriate management for a 55-year-old male with painful xerotic desquamation of the toes following recent antibiotic‑treated infection, now without active infection?

Treatment of Post-Infectious Xerotic Desquamation of the Toes

For a 55-year-old male with painful dry peeling skin on the toes following a treated infection, the primary treatment is aggressive emollient therapy with thick moisturizers applied multiple times daily, combined with gentle skin care and avoidance of irritants—antibiotics are not indicated since the infection has resolved.

Assessment and Differential Diagnosis

The clinical picture suggests post-inflammatory xerosis (dry skin) with desquamation rather than active infection, given that:

• The infection was already treated with antibiotics and has resolved
• No signs of active infection are present (no erythema, warmth, purulent drainage, or systemic symptoms mentioned)
• The primary complaint is dry, peeling, painful skin

Rule out fungal infection (tinea pedis): While the patient had a bacterial infection that was treated, the persistent peeling could represent an underlying or secondary fungal infection, particularly if the peeling involves the toe webs or has a scaly, erythematous border 1, 2. However, the description of "dry peeling skin" without mention of scaling, maceration, or characteristic distribution makes this less likely.

Primary Treatment: Emollient Therapy

Intensive moisturization is the cornerstone of treatment for xerotic skin:

• Apply thick, occlusive moisturizers (such as petroleum jelly, thick creams containing urea 10-20%, or ceramide-based products) at least 2-3 times daily, particularly after bathing when skin is still slightly damp 3
• For painful fissures or severe dryness, consider overnight occlusive therapy: apply thick emollient and cover with cotton socks 3
• Continue moisturizer treatment for weeks to months, as dry skin following inflammatory conditions can persist long after the acute process resolves 3

Supportive Skin Care Measures

Gentle skin care practices to prevent further irritation:

• Use mild, fragrance-free cleansers instead of harsh soaps 3
• Avoid hot water; use lukewarm water for bathing 3
• Pat skin dry rather than rubbing vigorously
• Avoid wool socks and synthetic materials that may increase friction; wear breathable cotton socks 4

When to Consider Alternative Diagnoses

Reassess for fungal infection if:

• Peeling persists despite 2-3 weeks of aggressive moisturization
• Scaling involves the toe webs with maceration or fissuring 1, 4
• There is an erythematous, scaly border suggesting tinea pedis 1, 2
• In these cases, obtain a potassium hydroxide (KOH) preparation or fungal culture, and treat with topical antifungals (such as terbinafine or azole creams) for 4 weeks if confirmed 1, 2

Reassess for recurrent bacterial infection if:

• New erythema, warmth, tenderness, or purulent drainage develops 3
• Systemic symptoms (fever, chills) appear 3
• In these cases, obtain wound cultures and restart appropriate antibiotic therapy 3

What NOT to Do

• Do not prescribe antibiotics for dry, peeling skin without signs of active infection, as this promotes antibiotic resistance and provides no benefit 3, 5
• Do not use topical antibiotics or antiseptics on non-infected dry skin, as they offer no benefit and may cause additional irritation 5, 6
• Avoid topical corticosteroids as routine treatment unless there is significant inflammation, as they can cause skin atrophy with prolonged use and do not address the underlying xerosis 3

Pain Management

For painful dry skin and fissures:

• The emollient therapy itself should reduce pain as the skin barrier heals
• If pain is severe, consider a brief course (3-5 days) of a low-potency topical corticosteroid (such as hydrocortisone 1%) combined with intensive moisturization to reduce inflammation 3
• Ensure proper offloading if the patient has diabetes or neuropathy, as painful fissures can become portals for infection 5, 6