Acta Dermato-Venereologica 99-12CompleteContent

See also In-this-Issue, p. 1070 CLINICAL REPORT Characteristics, Associated Diseases, and Management of Gram negative Toe-web Infection: A French Experience Anne GOISET 1,2 , Brigitte MILPIED 1 , Aurélie MARTI 2 , Jérôme MARIE 2 , Vaianu LEROY-COLAVOLPE 3 , Anne PHAM-LEDARD 1 , Olivier CHOSIDOW 4# and Marie BEYLOT-BARRY 1# Departments of Dermatology: 1 Bordeaux University Hospital, Bordeaux University, Bordeaux, 2 General Hospital, Périgueux, 3 General Hospital, Bayonne, and 4 Henri-Mondor Hospital, AP-HP, Paris-Est University Créteil (UPEC), Créteil, France # Contributed equally as last senior author. Gram-negative toe-web infection can cause pain and disability, be complicated by a long healing time, ma- nagement failure, and cellulitis, and recur due to per- sistent predisposing factors. To describe the clinical features and management of Gram-negative toe-web infection and evaluate predisposing factors and as- sociated diseases, their management, and the effect of controlling them on the rate of recurrence, we con- ducted a retrospective real-life study of patients with Gram-negative toe-web infection. Among the 62 pa- tients (sex ratio 9:1), 31 experienced more than one episode of Gram-negative toe-web infection. Pseu- domonas aeruginosa was the most prominent bacte- ria. Predisposing factors/associated diseases were eczema (66%), suspected Tinea pedis (58%), humi- dity (42%), hyperhidrosis (16%), psoriasis (11%), and vascular disorders (40%). Patients in whom as- sociated diseases, such as eczema or psoriasis, were controlled did not relapse, suggesting the benefit of management of such conditions. We suggest that ma- nagement of Gram-negative toe-web infection be stan- dardised, with a focus on diagnosis and treatment of associated diseases. Key words: Gram-negative toe-web infection; Pseudomonas aeruginosa; eczema; contact dermatitis. 1121 Accepted Sep 10, 2019; E-published Sep 10, 2019 Acta Derm Venereol 2019; 99: 1121–1126. Corr: Marie Beylot-Barry, MD, PhD, Department of Dermatology, Saint- André Hospital, Bordeaux University Hospital, 1 rue Jean Burguet, FR-33075 Bordeaux Cedex, France. E-mail: Marie.beylot-barry@chu- bordeaux.fr G ram-negative toe-web infection (GNTWI) is cha- racterised by marked denudation of the toe-web spaces, extending along the plantar surface with a well- delimited hyperkeratotic macerated rim and a purulent, sometimes greenish and malodorous exudate (1–5). Pseudomonas aeruginosa is the most commonly iden- tified of the various causative microorganisms (Proteus sp., Escherichia coli, Morganella morganii, Enterobacter sp., and Enterococcus faecalis) (2–4). The predisposing factors can be local or regional; i.e. interdigital tinea; occlusion; humidity; history of inappropriate treatment with antifungals, antibiotics, and topical corticosteroids; and contact/atopic eczema (2–5). SIGNIFICANCE Gram-negative toe-web infection is a disabling painful di- sease with long healing time and high recurrence rate. In a French retrospective real-life study, we described fea- tures and management of Gram-negative toe-web infec- tion and evaluated the effect of controlling predisposing factors/diseases on the rate of recurrence. Among the 62 patients included, mainly male, 31 experienced more than one episode. Pseudomonas aeruginosa was the prominent bacteria. Predisposing factors/associated diseases were eczema, suspected Tinea pedis, humidity, hyperhidrosis, psoriasis and vascular disorders. Patients in whom associa- ted diseases were controlled did not relapse. Subsequently, an algorithm of Gram-negative toe-web infection manage- ment is proposed with a focus on associated diseases. The long healing time and high recurrence rate of GNTWI make treatment challenging (2, 3, 5). Two small case series and a prospective study of 123 cases discussed the use of systemic antibiotics in severe and refractory GNTWI (2–4). However, the efficacy of sys- temic antibiotics has not been assessed, nor has the risk of development of antibiotic-resistant strains. In this retrospective multicentre study, we evaluated the clinical features, predisposing factors, and associated diseases of GNTWI, with the aim of proposing a standardised management algorithm. METHODS This real-life retrospective study was undergone in two univer- sity hospitals (Créteil and Bordeaux, and two general hospitals (Bayonne and Périgueux), all in France) from January 2011 to December 2017 (Fig. 1). The design was non-interventional and declared to the French national data-privacy agency (GP-CE 2018/21) in accordance with data-protection regulations. Infor- mation and non-opposition notes with our contact details were sent to the patients, all of whom were telephoned in July 2018 to verify receipt of the note. Case identification was based on the medical information system and dedicated software for inpatients and a photograph database for outpatients, with the key words “erythematous intertrigo” and “Pseudomonas aeruginosa” or “gram-negative bacilli.” We checked the medical records for the diagnosis of GNTWI based on clinical evidence (photographs and clinical description) and bacteriological swabs, or on clinical symptoms (2, 5). This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2019 Acta Dermato-Venereologica. doi: 10.2340/00015555-3315 Acta Derm Venereol 2019; 99: 1121–1126

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