TOE WEB MACERATION (PRESUMED GRAM NEGATIVE BACTERIAL INVOLVEMENT)
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FROM EDWARD GOMEZ, M.D., PH.D.

        I haven't treated this for some time but it was common when I was 
at Miami and NY.  When all else failed, esp if there was pseudomonas 
evident under the Woods lamp, we used an aqueous solution of IV 
gentamicin applied topically.  In those days many were inpatients and we 
just set up an IV bottle without a needle and driped it on 4x4's between 
the toes.  I don't know if the sensitivity remains the same but it was 
incredibly effective at the time.  Based on some cross-sensitivity assays 
done by Taplin's group we used to add the contents of a capsule of 
tetracycline to the IV bottle, but I stopped doing this because the 
gentamicin worked fine.

        During the acute "pus foot" phase, positive KOH's are rare.  If 
one goes back later, many have dermatophytes.  Whether this is the inciting 
cause and the inflammation cures the ones that are KOH negative is 
anyone's guess.  If you have recurrent episodes, topical antifungal 
prophylactic use should be considered.
 
     
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COMMENTS FROM DANIEL F. MITCHELL, M.D. 

I have the pt soak the foot for 15 min qid in DomeBoro solution, 
followed by application of gentian violet, with profuse warnings about 
staining.  The G.V. has tremendous placebo benefit because it is so 
nasty, besides killing everything known to man.  I usually culture, then 
cover with Cipro and often use a Prednisone taper as well, 60-40-20 over 
fifteen days.

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COMMENTS FROM Reviva@aol.com
 
I have found that the most important aspect of the treatment of this problem
is to mechanically debride the necrotic tissue.  Once all of the necrotic
debris is removed, I have found that once the necrotic debris is removed,
topical treatment with a combination of gentamycin cream and nizoral cream
will eradicate any remaining infectious process.  Then compulsive foot care
with thorough drying and Zeasorb AF powder, changing shoes frequently, etc.
is of utmost importance to prevent recurrence.  If recurrence starts, get on
it with topical creams ASAP. 


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(archived 25 June 1995)