Treating Secondary Infection In A Patient With Severe Tinea Pedis

Michael Moharan, DPM, Mohamed Abdelmegeed Ahmed, MD, DPM, and Oleg Karpenko, MD, DPM

   The initial treatment was minor debridement of the wound with application of gentian violet and prescription terbinafine (Lamisil, Novartis) PO. He also received topical econazole nitrate (Spectazole cream, Janssen Pharmaceuticals) and hydrocodone (Vicodin, Abbott Laboratories) for pain management. At a fourth week of follow-up, he had decreases in edema, exudate, pain and the size of the wound. The physician recommended he continue topical antifungal therapy for three more weeks.

   At the two month follow-up, the patient had an increase in the width and length of the wound with edema and erythema of skin of the right foot and serous exudates from the wound. The patient received aseptic debridement of the wound, topical gentian violet application and prescribed amoxicillin clavulanate (Augmentin, GlaxoSmithKline) PO and topical Betadine ointment (Purdue Pharma) for two weeks with no relief.

   Four months after the original admission to the wound care center, the patient was admitted again to the center with tinea pedis complicated with cellulitis and chronic ulcers of the third and fourth interdigital space of the right foot. He received antifungal treatment with terbinafine PO, topical econazole nitrate cream, gentian violet and a Xeroform petrolatum dressing (Covidien), and pain management with hydrocodone. After four weeks with no improvement, physicians added griseofulvin (Gris-PEG, Pedinol) PO and naftifine gel (Naftin, Merz Pharmaceuticals) to the treatment regimen. Physicians discontinued terbinafine PO and econazole nitrate cream, and continued hydrocodone for pain management.

   Two months later, the patient had complaints of a painful, swollen right foot and an open, tender pruritic lesion of the third and fourth interspace and dorsal aspect of the second through the fifth toes of the right foot. His condition was getting progressively worse with severe pain on ambulation and pain in all type of shoes, causing him to miss work. The patient was taking griseofulvin 250 mg TID, hydrocodone, and topical naftifine gel, He was also using a Xeroform petrolatum dressing and a controlled ankle motion walker.

   His vascular, neurologic and orthopedic exams were normal. X-rays showed no radiographic evidence of osteomyelitis. We obtained wound cultures. Initial treatment consisted of a therapeutic injection with lidocaine (Xylocaine, Astra Zeneca) and bupivicaine (Marcaine) for pain relief, application of gentian violet and prescribing Pedi-Dry, Betadine soak gauze and lidocaine patches with weekly follow-up.

How The Patient Fared During Follow-Up

On the first follow-up, we added empiric antibiotic therapy with amoxicillin clavulanate PO and piroxicam (Feldene, Pfizer) PO for pain management to the treatment regimen. The culture came back positive for gram-negative Pseudomonas aeruginosa. We added levofloxacin (Levaquin, Ortho-McNeil) PO with amoxicillin clavulanate d/c and topical silver sulfdiazine (Silvadene, Monarch Pharmaceuticals) to his treatment. At the two week follow-up visit, treating the affected area with levofloxacin PO showed much success with decreased edema, erythema, width, length and depth of the wound and a 100 percent granular base of the lesion.

   However, in the next three weeks, the patient started feeling severe pain on ambulation, itching and a burning sensation in interdigital spaces three to four on the right foot. He also had increased swelling and hyperemia of the right foot. In regard to the physical exam, the Wood’s lamp was positive. We suspected an erythrasma superinfection and prescribed erythromycin with continued Betadine soak gauze and daily local wound care. We saw the patient on a weekly basis and provided local wound care. Due to persistent severe pain, we added hydrocodone for pain management. His condition significantly improved, his skin showed excellent signs of healing and the Wood’s lamp test showed resolution of erythrasma. We subsequently referred the patient to physical therapy to help reduce pain and increase the range of motion of the right foot.


I have seen patients with Pseudomonas aeruginosa infection secondary to interdigital fungi infection. Instead of using topical cream, I use silver dressing with exudate control ability such as Aquacel Ag or Acticoat with aligiste m, together with oral antibiotics. The infected toe webs dried up, became less swollen and the foot healed up within two weeks.

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