Interdigital maceration

Interdigital maceration of the skin occurs when the normal balance of the water content is disrupted because of either excessive production of moisture (ie sweating) or if the evaporation of that moisture is impaired (ie between the toes). This causes a white and ‘soggy’ appearance to the skin between the toes that alters the normal microbiological flora that increases the risk for a secondary bacterial or fungal infection. The maceration could be a primary problem or an indication of that secondary infection.

The maceration weakens the skin structure and predisposes it to a fissure between the toes. The continual exposure to moisture damages the integrity of the stratum corneum layer of the epidermis, affecting its ability to act as a protective barrier and reduces the skins mechanical strength.

Risk factors include hyperhidrosis, poor foot hygiene practices (failure to dry between toes), oedema (compression between toes), too much footwear use (prevents evaporation of moisture). Using creams between the toes may also increase the risk for this.

Clinical Features of Interdigital Maceration:
The skin in the spaces between the toes appears white and ‘soggy’. There may be some peeling of the skin.
A foul odor may be present.
Generally it is not itchy (a fungal infection typically is).

Need to rule out other causes, that would affect the treatment options.
Differential diagnosis: ‘Toe jam‘; Heloma molle (soft corn); interdigital fissure; interdigital erythrasma, psoriasis alba, tinea pedis (can appear exactly the same), scabies, erosio interdigitalis blastomycetica.

Interdigital space maceration treatment:
Good foot hygiene – clean the feet, wash and dry between the toes. A thin towel is often recommended to dry between the toes. Advice may need to be given to care givers if self-care is a problem. There are foot care aid products available to help this.
Exposing the feet to the air; going barefoot – for a long enough period to allow the skin to dry.
Toe spacers can be used in the short term to help dry out the area.
Regularly change to dry shoes and socks to help absorb moisture.
Absorbent wound dressings could be tried in the short term.

Topical applications:
a) Astringent solutions have a drying effect on the skin: eg Witch hazel, surgical spirit, Tincture of benzoin (Friar balsam); silver nitrate – astringents may be painful if there is a fissure in the skin. They are best applied with cotton wool buds.
b) Evaporative solutions dry the skin as they evaporate: eg surgical spirit; Povidine iodine in alcohol (eg Betadine) (may also help with mild fungal infection) – advice needs to be given to remain barefoot long enough for the evaporation to occur.
c) Powders soak up the moisture and are often recommended, however the powder can also restrict the skin pores, possibly increasing the risk for infection and they do not absorb all that much moisture. They will help reduce friction on the skin between the toes if this is an issue.

Oral antibiotics or anti-fungal medications if any infection present is problematic.

External Links:
Treating idiopathic interdigital maceration (Podiatry Arena)

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