Toe Web Infections, the Microbiome, and Toe Web Psoriasis: A Review

OBJECTIVE

To present the toe web space as an anatomically, physiologically, and pathologically unique part of the human body; characterize toe web infections and discuss why they occur; and highlight toe web psoriasis as an uncommon condition that providers should consider if toe web intertrigo does not respond to treatment.

DATA SOURCE

This review encompassed many years of clinical observation and photographs; medical textbooks; and a literature search of MEDLINE, PubMed, and Google Scholar.

STUDY SELECTION

Primary research keywords included intertrigo, toe web intertrigo, toe web infection, tinea pedis, microbiome, skin microbiome, toe web microbiome, ecology, psoriasis, psoriasis microbiome, intertriginous psoriasis, and Wood's lamp. More than 190 journal articles met the search criteria.

DATA EXTRACTION

The authors sought data relating to what makes for a healthy toe web space and what makes for disease. They extracted and collated relevant information to compare and contrast among sources.

DATA SYNTHESIS

After understanding the normal toe web space and the microorganisms that normally reside there, the authors investigated why infections occur, how they should be treated, what complications may result, and what other diseases occur in the toe web area.

CONCLUSIONS

This review of toe web infection illustrates the effect of the microbiome and reports a rare form of psoriasis that is usually misdiagnosed as athlete's foot. The toe web space is a unique part of the human body that can be affected by a variety of both common and unusual conditions.

Skin findings associated with obesity

We are facing an obesity epidemic in adolescents in the United States. Thus, practitioners will need to become familiar with cutaneous findings associated with obesity in order to diagnose and treat them properly. This article addresses some of the cutaneous findings associated with obesity.

[How I treat....A stoutness-associated intertrigo]

Intertrigo is a common inflammatory disorder of various origins. It can represent a single skin manifestation or be part of a disorder possibly exhibiting specific manifestations on other parts of the body. Hence, intertrigo may represent a sign of a peculiar disease. It may also result from physicochemical aggressions of the skin following occlusion of the large skinfolds particularly in case of stoutness. In this intance, a treatment similar to that of diaper dermatitis can be offered. A paste enriched or not with miconazole nitrate is indicated to prevent or treat most presentations of intertrigo.

Etiologic and causative factors in perianal dermatitis: results of a prospective study in 126 patients

BACKGROUND

Perianal dermatitis is probably the most common cutaneous disorder of the genitoanal area. Studies on the epidemiology of causative factors are rare.

METHODS

Over a 4-year period we prospectively studied 126 patients with a presumptive diagnosis of anal eczema. The diagnostic algorithm comprised medical history, inspection, microbiology, laboratory chemistry, patch tests, proctoscopy, and biopsy if appropriate.

RESULTS

The age range was 7-82 years and the majority of patients were male (57.1%). Periods of anal symptomatology ranged from 6 days to 120 months and most of the patients (51.6%) had complaints for more than 12 months. The clinical diagnosis in 68 patients (54%) was: intertrigo/candidiasis (42.9%), atopic dermatitis (6.3%), pruritus ani (5.6%), psoriasis (3.2%), skin atrophy from steroid use (2.4%), lichen sclerosus et atrophicus (n = 2), herpes simplex (n = 1), and condylomata acuminata (n = 1). Contact eczema was suspected in 58 patients (46%), but 25 of these (43.1%) showed no contact sensitization.

CONCLUSION

The majority of patients with symptoms of anal eczema suffer from intertrigo/candidiasis, and relevant, causative contact sensitization may be found in only some of them. Patch-testing is a valuable investigative tool only when the patients' own products are included in the test series. Most patients suffer from their perianal complaints for more than 12 months, therefore diligent evaluation is warranted.

Intertrigo and common secondary skin infections

Intertrigo is inflammation of skinfolds caused by skin-on-skin friction. It is a common skin condition affecting opposing cutaneous or mucocutaneous surfaces. Intertrigo may present as diaper rash in children. The condition appears in natural and obesity-created body folds. The friction in these folds can lead to a variety of complications such as secondary bacterial or fungal infections. The usual approach to managing intertrigo is to minimize moisture and friction with absorptive powders such as cornstarch or with barrier creams. Patients should wear light, nonconstricting, and absorbent clothing and avoid wool and synthetic fibers. Physicians should educate patients about precautions with regard to heat, humidity, and outside activities. Physical exercise usually is desirable, but patients should shower afterward and dry intertriginous areas thoroughly. Wearing open-toed shoes can be beneficial for toe web intertrigo. Secondary bacterial and fungal infections should be treated with antiseptics, antibiotics, or antifungals, depending on the pathogens.

Preventing and treating intertrigo in the large skin folds of adults: a literature overview

Intertrigo is an inflammatory dermatosis of the skin folds of the body, for which a large variety of topical medications may be recommended. A systematic literature review was performed to find scientific evidence for preventing and treating intertrigo within the nursing domain. Seven electronic databases were searched with a simple broad-scope search strategy. The aim was to identify all publications that concerned intertrigo itself and other conditions that were related to intertriginous regions. This search produced 451 references. A final set of 24 studies was retained and analyzed on content and methodologic quality. Most studies concerned treatments with antifungals or disinfectants in heterogeneous research samples, with only small subsamples of people with intertrigo. Six studies were randomized controlled trials. In general, the methodologic quality of the studies was poor. The analyzed studies provided no scientific evidence for any type of nursing prevention or treatment strategy. There is a great need for well-designed clinical studies on intertrigo.

Acute genitocrural intertrigo: a sign of primary human immunodeficiency virus type 1 infection

We describe a 49-year-old male patient who presented with an acute illness associated with a widespread maculopapular eruption and eroded lesions in the inguinal folds consistent with an acute intertrigo, for which search of mycological and bacteriological causes remained negative. Serological tests disclosed a high viral HIV-1 load and p24 antigenemia, while anti-HIV-1 antibodies were absent, a profile typical of acute HIV-1 infection. Since the maculopapular eruption regressed concomitantly with the orogenital lesions as well as the eroded inguinal lesions prior to specific therapy, our observation indicates that intertriginous lesions may constitute one of the early cutaneous markers of primary HIV-1 infection.

Labiomental intertrigo. An indication for orthognathic surgery

Severe skeletal retrognathia may lead to a pronounced labiomental fold. When severe the labiomental fold may result in intertrigo, which is chronic and symptomatic. This problem can be managed by orthodontics and orthodontic surgery to reposition the jaw at a more anterior direction, thus creating a normal lip posture and a normal labiomental fold.

[Cutaneous complications of massive obesity]

Massive obesity leads to nonspecific skin disorders. Skin folds are more numerous and deeper in the obese subject, and can become the site of various disorders. Hence the difficulty of diagnosis and treatment is increased. Acanthosis nigricans should be recognized, but not solely attributed to obesity, since other causes, particularly cancer, may be involved. Finally, leg ulcerations, a frequent consequence of the venous insufficiency inherent in obesity, should not lead to overlook other underlying causes, particularly in diabetic patients.