Toe Web Research Articles

Trichophyton tonsurans scalp carriage among wrestlers in a national competition in Turkey

Trichophyton tonsurans tinea gladiatorum is an emerging epidemic among combat-sport athletes across the globe. In the present study, we investigated the prevalence of symptomatic and asymptomatic dermatophytic infections among wrestlers in the National Greco-Roman Championship in Turkey. In total, 194 wrestlers from 32 provinces and 72 clubs were examined for scalp, trunk, groin, and toe web dermatophytic infections. We also administered a questionnaire to obtain information on the participants' lifestyles, wrestling characteristics, and risk factors for dermatophytic infections. The hairbrush method was used for scalp and trunk sampling, whereas a cotton swab was used for groin, toe web, and mat sampling. Three wrestling mats in the gymnasium were surveyed for dermatophytes using the touch preparation method. A total of 17 (8.8%) wrestlers harbored dermatophytes, and 22 strains were isolated: 13 (59.1%) T. tonsurans and 9 (40.9%) T. rubrum. These isolates were found on the scalp (8), trunk (2), forearm (1), hand (1), groin (3), and feet (7). In addition, we recovered 8 dermatophyte strains from the 150 mat samples (5.3%): T. rubrum in 6 samples (75%) and T. tonsurans in two samples (25%). T. tonsurans was only recovered from 11 out of 194 (5.7%) wrestlers. Scalp carriage represents the predominant (72.7%) clinical picture of a T. tonsurans infection in these Greco-Roman wrestlers in Turkey.

Measuring amphibian immunocompetence: validation of the phytohemagglutinin skin‐swelling assay in the cane toad, Rhinella marina

Summary 1. Measuring the degree of skin‐swelling induced by intradermal injection of phytohemagglutinin (PHA) is simple, quick and inexpensive, does not require specialized equipment and is easily conducted under field conditions. 2. PHA is perhaps the most frequently used assay of immunocompetence in field studies of birds. However, the method has rarely been used, and never validated, for studies on ectothermic vertebrates. 3. Here, we document its use in an amphibian. In response to PHA injected into a toe web, cane toads exhibited a 35% increase in web thickness 24 h postinjection. 4. Histologically, PHA injection initiated a rapid (<12 h) infiltration of neutrophils, eosinophils and macrophages at the injection site, followed by an influx of lymphocytes by 24 h postinjection. A second exposure to PHA stimulated a faster, more intense swelling response. 5. In cane toads, PHA injection elicits a rapid innate immune response, followed by a secondary response that may reflect cell‐mediated immune activity. Both components are easily quantifiable by the degree of skin‐swelling. 6. Hence, PHA injection offers a convenient assay to quantify immune function in anurans and could usefully be incorporated into studies on the reasons for global amphibian declines.

Plantar verrucous carcinoma masquerading as toe web intertrigo

A 77-year-old man presented with a 6-month history of intractable toe web intertrigo located in the third and fourth web spaces of his left foot. Biopsy and histological examination confirmed the presence of a verrucous carcinoma. Verrucous carcinoma of the foot has been called epithelioma cuniculatum, a case arising in the intertriginous area of the foot is presented.

Communicating Branch of Toe Web Veins as a Venous Return Pathway in Free Toe Pulp Flaps

Communicating Branch of Toe Web Veins as a Venous Return Pathway in Free Toe Pulp Flaps

Screening for Acinetobacter baumannii Colonization by Use of Sponges

There is currently no consensus method for the active screening of Acinetobacter baumannii. The use of swabs to culture nostrils, pharynx, and skin surface of various anatomical sites is known to yield less-than-optimal sensitivity. In the present study, we sought to determine whether the use of sterile sponges to sample large areas of the skin would improve the sensitivity of the detection of A. baumannii colonization. Forty-six patients known to be colonized with A. baumannii, defined by a positive clinical culture for this organism as defined by resistance to more than two classes of antimicrobials, participated in the study. The screening sites included the forehead, nostrils, buccal mucosa, axilla, antecubital fossa, groin, and toe webs with separate rayon swabs and the forehead, upper arm, and thigh with separate sponges. Modified Leeds Acinetobacter medium (mLAM) agar plates that contained vancomycin and either aztreonam or ceftazidime were used as the selective medium. An enrichment culture grown overnight substantially increased the sensitivity for most sites. The sensitivity ranged between 69.6 and 82.6% for individual sponge sites and 21.7 to 52.2% for individual swab sites when mLAM plates with ceftazidime were inoculated after a 24-h enrichment period. The sponge and swab sites with the best sensitivity were the leg and the buccal mucosa, respectively (82.6% and 52.2%; P = 0.003). The combined sensitivity for the upper arm and leg with a sponge was 89.1%. The novel screening method using sterile sponges was easy to perform and achieved excellent sensitivity for the detection of A. baumannii colonization.

Evaluation of the association of superficial dermatophytosis and athletic activities with special reference to its prevention and control

This study was conducted to evaluate the association of superficial mycosis and athletic activities with special references to its prevention and control in Tehran. Participating in various kinds of sports can lead to direct and indirect exposures to and transmission of micro-organisms between athletes and also passive observers. A retrospective study of superficial fungal infections in athletes was carried out during the period of March 2002 to December 2006 on 656 mycological proven cases of dermatophytosis found in athletes in Tehran. Mycologic examination consisted of culturing of pathologic material followed by direct microscopic observation. Mycologic cultures were carried out on Sabouraud Chloramphenicol Agar, Sabouraud Chloramphenicol and Cyclohexamide Agar, and Dermatophyte Agar incubated at 25 °C for at least 28 d. Diagnosis was based on macroscopic and microscopic characteristics of the colonies. A total of 1075 athletes, from 201 institutions, suspected of cutaneous fungal infections were examined and 656 (61%) were found to be positive for fungal infections. The fungal isolates comprised Trichophyton tonsurans (56%), Epidermophyton floccosum (11.8%), Trichophyton mentagrophytes (8.9%), Trichophyton rubrum (8.3%), Trichophyton verrucosum (3.9%), Trichophyton violaceum (3.3%), Microsporum canis (2.5%), and Malassezia spp. (5.3%). The distribution of lesions on the body in decreasing order was as follows: trunk, groin, hair and scalp, sole, toe webs, finger nails, and toe nails. Fungal infections were more commonly seen in wrestlers and individuals that participate in aerobics. The results suggest that athletic activity seems to be a predisposing factor, especially for fungal infections. Guidelines are provided regarding measures to prevent transmission of infectious diseases in athletic settings, including hygiene, infection control practices, and education of officials, coaches, trainers, and sports participants.

Endoscopic Distal Soft-Tissue Release in the Treatment of Hallux Valgus: A Cadaveric Study

To study the efficacy and safety of the lateral release of the endoscopic distal soft-tissue procedure in the treatment of hallux valgus. Twenty fresh-frozen foot and ankle specimens were used. Ligament-sacrificing release was performed in 10 specimens (group 1). Ligament-sparing release was performed in another 10 specimens (group 2). The relation between the metal rod that passed through the toe web and plantar portal wounds and neural structures, degree of completeness of release of the intermetatarsal ligament, adductor hallucis insertion, and lateral capsular structures was studied. The common digital nerve of the first intermetatarsal space ran along the medial side of the rod, the medial digital nerve of the second toe ran obliquely and plantar to the rod just proximal to the proximal edge of the intermetatarsal ligament, and the lateral digital nerve of the hallux ran along the plantar lateral border of the metatarsal head and fibular sesamoid in all specimens. The intermetatarsal ligament, adductor hallucis insertion, and lateral capsular ligamentous structures were released completely in all specimens in group 1. The intermetatarsal ligament was preserved and the lateral capsular ligamentous structures were completely released in all specimens in group 2. The adductor hallucis insertion was completely released in 7 specimens. No nerve injury or cartilage damage was noted in all 20 specimens. With the release of the intermetatarsal ligament, all lateral capsular ligamentous structures including the adductor were released, but with intermetatarsal ligament preservation, only 70% of the specimens had complete adductor release. There was no neural or articular cartilage damage in either group. The study provides an anatomic basis for safe practice of endoscopic distal soft-tissue release in the correction of hallux valgus deformity.

Composite flap transfer from the foot for treatment of multi-finger complex soft tissue defects

Objective To introduce the clinical application of composite flap transfer from the foot for treatment of multi-finger complex soft tissue defects. Methods This method was applied to treat 7 cases and 19 fingers. All the cases involved complex dorsal soft tissue defect of 2 to 4 fingers with extensor tendons missing and phalanx or interphalangeal joint exposed. The combined soft tissue defect area was 5.0cm×1.5cm to 9.0 cm× 2.5 cm. The flaps were designed along the axis extending from the fibular and plantar margin of the great toe to the interspace between the first and second metatarsal bones. The flap was slightly larger than the dorsal finger defect combined and the shape of the flap was the same as the combined defect. The greater saphenous vein, dorsal digital veins and dorsal metatarsal or plantar metatarsal artery and nerves were included in the flap. They were sutured with dorsal digital veins, digital artery and nerves, respectively. Extensor digitorum brevis tendons and extensor digitorum longus tendons were included in the flap to reconstruct the missing tendons. Results All the flaps survived with good texture and good appearance. Two-point discrimination recovered 6 to 8 mm. Finger extension function was restored, and active finger flexion and extension recovered satisfactorily. The donor feet were with slight scar, good appearance and normal function. Conclusion Combined dorsalis pedis,toe web and great toe fibular flap including extensor digitorum brevis and extensor digitorum longus tendon is a good option to treat multi-finger dorsal complex defects. Key words: Surgical flaps; Finger injuries; Tendon injuries; Transplantation

Prevalence of cutaneous fungal infections among sports-active individuals

Background: This study was conducted to evaluate the occurrence of cutaneous fungal infections affecting athletes. Methods: A respectively study of superficial fungal infections in athletes was carried out during the period March 2002 to December 2006 on 656 mycologically proven cases of dermatophytosis found in athletes in Tehran. Mycological examination consisted of culturing of pathologic material followed by direct microscopic observation. Mycological cultures were carried out on Sabouraud Chloramphenicol Agar, Sabouraud Chloramphenicol and Cyclohexamide Agar, and Dermatophyte Agar incubated at 25° C for at least 28 days. Diagnosis was based on macroscopic and microscopic characteristics of the colonies. Results: We surveyed 1075 athletes suspected of having cutaneous fungal infections from 201 institutions and found that 656 (61%) were positive for fungal infections. The fungal isolates comprised Trichophyton tonsurans (56%), Epidermophyton floccosum (11.8%), Trichophyton mentagrophytes (8.9%), Trichophyton rubrum(8.3%), Trichophyton verrucosum (3.9%), Trichophyton violaceum (3.3%), Microsporum canis (2.5%), Malassezia fur fur (3.3%), and Pityrosporum oval (2%). The distribution of the lesions on the body was: trunk> groin> hair and scalp> sole and toe webs> finger nails> toe nails. Fungal infections were more commonly seen in wrestlers and aerobics. Conclusion: The results suggest that athletic activity seems to be a predisposing factor, especially for fungal infections.

Extraskeletal Osteochondroma of the Foot

Extraskeletal osteochondroma, an infrequently encountered benign lesion, is described in 1 patient who presented with a slow-growing, relatively painful mass on the dorsal side of his right foot, in the 3rd toe web. Radiographs and magnetic resonance imaging studies demonstrated a radio-opaque extraskeletal mass. Excision biopsy revealed a well-defined and lobulated, firm, calcified, extraskeletal mass, which was easily enucleated. Histologic examination revealed mature chondroid tissues with bland-looking chondrocytes and ossified tissues. The diagnosis of an extraskeletal osteochondroma should be considered when a discrete ossified mass is localized in the soft tissues of the distal extremities. A case of pathologically proven extraskeletal osteochondroma is presented together with clinical, radiologic, and magnetic resonance imaging findings, and a literature review.

Association of human papillomavirus 7 with warts in toe webs

There have been no studies on the prevalence of types of human papillomavirus (HPV) in cutaneous warts that focus on warts in toe webs (WTW). There is no documented association between HPV 7 and WTW. To explore the clinical and histopathological features of WTW, and the distribution of HPV genotypes in patients with WTW. The study group consisted of 20 patients with WTW; 31 patients with typical verruca vulgaris (VV) were enrolled as the disease control group, and 53 patients with tinea pedis and 48 healthy volunteers were enrolled as the disease-negative control group. Tissue specimens were analysed for clinical and histological features and distribution of HPV genotypes. Polymerase chain reaction (PCR)-based direct sequencing, TA cloning and type-specific PCR (TS-PCR) were performed in the WTW and VV groups. Interdigital scale specimens from patients with tinea pedis and from healthy volunteers were analysed for HPV DNA by nested PCR and TS-PCR (HPV 7). All the patients with WTW were male and nearly all were immunocompetent; their mean age was 41 +/- 10 years. The lesions presented mainly as soft, friable and vegetating clusters. HPV 7 was the predominant genotype in WTW with a frequency of 80% (16/20). Fourteen specimens were taken for histopathological examination. The most frequent histological results (seven out of 14) revealed characteristics of HPV 7 infections such as heavily stained cells containing medium-sized keratohyaline granules and a pronounced hyperkeratosis with parakeratosis. TA cloning showed that the sequence shared 90% or more homology with the HPV genotype in direct sequencing. No HPV 7 DNA was found in the scales taken from toe webs without warts. This is the first study evaluating the prevalence of HPV types in WTW and the first report of the association between HPV 7 and specific subgroups of patients with warts.

Clinical and mycological study of the macerated toe web in Egypt.

Zusammenfassung 448 nicht ausgesuchte ambulante Patienten des Hospitals der Ain Shams-Universitat wurden klinisch auf Pilzbefall-der Zehengewebe untersucht. 174 davon waren Manner, 274 waren Frauen. Zeichen von Tinea interdigitalis pedis wiesen 54 (= 31,1%) Manner und 92 (= 33,6 %) Frauen auf. Aufgrund dieser orientierenden Voruntersuchung wurden nun 304 Falle mit klinischen Erscheinungen mykologisch untersucht, 89 Manner und 215 Frauen. Das Alter betrug meist zwischen 11 und 50 Jahren, unter 10 Jahren waren nur 3 Personen, uber 50 Jahre deren 12. Das Nativpraparat erwies sich in 112 Fallen als positiv; nicht nur Pilzfaden, sondern auch sicher erkennbare Sproszellen wurden als “positiv” gewertet. Kulturell wurden in weitaus uberlegener Anzahl Hefen der Gattung Candida gezuchtet, insgesamt 64,4 %, nur eine verhaltnismasig geringe Anzahl von Dermatophyten, namlich 4,6 %, und 10, 5 % Schimmelpilze. Die Differenzierung der Pilze ergab: 164 C. albicans, 4 C. tropicalis, 2 C. stellatoidea, 2 C. catenulata, 24 nicht identifizierte Candida-Hefen; 12 Trichophyton rubrum und 2 T. mentagrophytes. Die besondere Rolle von C. albicans, die nicht zur normalen, sondern zur pathogenen Hautflora gehort, wird diskutiert. Die enttauschenden Ergebnisse der Grieofulvinbehandlung bei Hefebefall werden hervorgehoben. Die Behandlung mit Candida-wirksamen Medikamenten ist erforderlich.

Epidemiology and prevalence of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis in patients with diabetic foot ulcers: Focus on the differences between species isolated from individuals with ischemic vs. neuropathic foot ulcers

We examined whether foot ischemia or neuropathy with diabetic foot ulcer (DFU) promote selection of staphylococci species, evaluated frequency of MRSA and MRSE among strains yielded from patients with DFU and assessed multidrug resistance of isolates. Patients with DFU and foot osteomyelitis were divided into ischemic foot ulcer (IFU, n = 21) and neuropathic foot ulcer (NFU, n = 29) groups. Frequency of Staphylococcus epidermidis yielded from curettage of IFU was higher compared with NFU ( P < 0.05). S. epidermidis was also more frequently isolated from the toe web surface of patients with IFU compared with NFU (55% vs. 17.9%, respectively) and healthy volunteers (HV, n = 20) (17.6%, P < 0.05). These mostly MRSE strains (83.3–100%) originating from DFU patients were multidrug resistant (88.8%). Also, most of MRSA isolates were multidrug resistant (70.3%). Higher rates of MSSA from DFU patients than HV showed resistance to antimicrobials. This is the first report indicating that diabetic patients with IFU differ with NFU patients in higher frequency of S. epidermidis skin colonization and ulcer infection. We suggest that IFU should be defined as separate disease state of DFU and S. epidermidis should be appreciated as a nosocomial pathogen.

Visual Diagnosis: A 5-year-old Male Who Has an Intensely Pruritic Maculopapular Rash

1. Saad Siddiqui, MD* 2. Vimal Master Sanker Raj, MD* 3. Arthur N. Feinberg, MD* 1. *College of Human Medicine, Michigan State University, Kalamazoo Center for Medical Studies, Kalamazoo, Mich A 5-year-old boy presents to the clinic having a 3-day history of rash and itching. The rash started in the periumbilical area and spread to both sides of the groin. The child has severe pruritus causing persistent crying and inability to sleep at night. There is no history of fever or systemic symptoms. No other family members are affected. Of note, the family recently went on a summer camping trip in northern Michigan. The child's general health has been good; he has no documented allergies and is receiving no medication. However, the family expressed concern about allergies (rhinitis) during the last health supervision visit and mentioned that there are several pets in the home. There is no known exposure to farm animals or grain. Physical examination reveals a red, maculopapular rash clustered in the periumbilical area (Fig. 1), with spread to the groin. Another lesion is in a finger web and a third in a toe web. There is no bleeding, excoriation, infection, or burrowing. There is no involvement of the face or buttocks. A clinical diagnosis is made. Figure 1. Erythematous, maculopapular rash clustered on trunk and periumbilical region. The clinical diagnosis was based on the physical findings of typical skin allergic/inflammatory reactions with absent burrowing on unexposed areas of the skin plus the history of outdoor exposure during warmer months. Ultimately, the patient's rapid recovery helped confirm the initial impression. ### Discussion There is little mention of chigger bites in standard pediatric textbooks. This case illustrates how to identify, treat, and prevent chigger bites. Pruritic skin rashes usually evoke consideration of eczema or urticaria. If insect bites are suspected, the clinician typically searches for an area of entry (punctum), but papular urticaria at the initial insect bite site may recur without puncta for months in the same areas. The phylum Arthropoda , …

Dermatophytes and other skin mycoses found in featherless broiler toe webs

Background: Feartherless broilers which are produced by a complex breeding programme from feathered parents carrying the Sc-gene, dissipates excessive body heat under hot and humid conditions. It has high body weight, and grows very rapidly when compared with standard commercial broilers. Their toe webs are bigger than standard commercial broilers, and could harbor fungi which can cause infections where there is the opportunity. Objectives: To isolate and identify the presence of fungi in toe webs of featherless broilers. Methods: A total of 50 featherless broilers' toe webs samples were examined microscopically for the presence of fungi. The samples were examined microscopically and culturally using standard microbiological techniques. Results: The fungi recovered were as follows. Microsporum gypseum 9 (22%), Trichophyton mentagrophytes var. mentagrophytes 5 (12%), Microsporum gallinae 3 (7%), Aspergilus flavus 10 (24%), Fusarium sp 6 (15%), Alternaria alternata 3 (7%) Scopulariopsis brevicaulis 2 (5%) and Candida albicans 3 (7%), Conclusion: The featherless broilers' toe webs habour fungi which cause mycotic skin disease and cannot be regarded as ordinary normal flora of toe webs

Acute Bacterial, Nonnecrotizing Cellulitis in Finland: Microbiological Findings

Bacterial, nonnecrotizing cellulitis is a localized and often recurrent infection of the skin. The aim of this study was to identify the beta-hemolytic streptococci that cause acute nonnecrotizing cellulitis infection in Finland. A case-control study of 90 patients hospitalized for acute cellulitis and 90 control subjects was conducted during the period of April 2004-March 2005. Bacterial swab samples were obtained from skin lesions or any abrasion or fissured toe web. Blood culture samples were taken for detection of bacteremia. The patients, their household members, and control subjects were assessed for pharyngeal carrier status. beta-Hemolytic streptococci and Staphylococcus aureus were isolated and identified, and group A and G streptococcal isolates were further analyzed by T serotyping and emm and pulsed-field gel electrophoresis typing. beta-Hemolytic streptococci were isolated from 26 (29%) of 90 patients, 2 isolates of which were blood-culture positive for group G streptococci, and 24 patients had culture-positive skin lesions. Group G Streptococcus (Streptococcus dysgalactiae subsp. equisimilis) was found most often and was isolated from 22% of patient samples of either skin lesions or blood, followed by group A Streptococcus, which was found in 7% of patients. Group G streptococci were also carried in the pharynx of 7% of patients and 13% of household members but was missing from control subjects. Several emm and pulsed-field gel electrophoresis types were present among the isolates. Six patients (7%) had recurrent infections during the study. In 2 patients, the group G streptococcal isolates recovered from skin lesions during 2 consecutive episodes had identical emm and pulsed-field gel electrophoresis types. Group G streptococci, instead of group A streptococci, predominated in bacterial cellulitis. No clear predominance of a specific emm type was seen. The recurrent nature of cellulitis became evident during this study.

Commentary on: “Athletes Foot: When All Else Fails” by William C.R. Agunwa [Foot Ankle Surg. 12 (2006) 209–210

126 doi nterdigital, with itching, peeling, maceration and fissuring of the (usually lateral) toe webs. Here the fissuring is important as a portal of entry for bacterial infection. 2. M occasin pattern with diffuse erythema and scaling affecting the whole of the soles and sometimes the feet’s lateral aspects. The scaling is often maximal along plantar creases and may also show collarette patterning. This variety is most likely to be associated with toe nail infection and a similar (usually unilateral) involvement of the palms. 3. V esicular infection, with a patch of erythema, scaling and vesiculation on either the soles or dorsa of the feet.

Necrolytic migratory erythema in an opiate-dependent patient

An 18-year-old woman presented with severe features of seborrhoeic dermatitis involving her scalp. Subsequently, the toe webs and intertriginous areas became affected by an erythematous, slightly scaly and weepy rash. The groin area was most severely affected, and complicated by intermittent infections with staphylococci and herpes simplex. The patient admitted to smoking heroin and was subsequently enrolled in a methadone programme. A biopsy from the groin area showed a combination of parakeratosis and keratinocyte vacuolar changes, supporting a diagnosis of necrolytic migratory erythema (NME). On completion of methadadone withdrawal, the rash cleared. The rash returned upon recommencing methadone. NME consists of an irregular annular eruption with an erythematous crusted edge. It is often mistaken for intertrigo or seborrhoeic dermatitis. In this patient, a direct effect of heroin and methadone on the epidermal metabolism might be speculated. There could be a variant of the opiate recepter, which is especially sensitive to the effects of opiates. This is the second case occurring in association with opiate dependency and the first case where the patient was rechallenged, although the precise role of the opiates in the aetiology remains somewhat speculative.

Recent considerations in recurrent cellulitis

Cellulitis is a frequently diagnosed syndrome that causes considerable morbidity. For a subset of patients, recurrent bouts of infection impact their quality of life. Most cases are due to beta-hemolytic streptococci or Staphylococcus aureus. Inclusion of interdigital space (toe web) or mucosal (anal) swab cultures may increase the ability to define pathogens among patients with lower extremity cellulitis. The pathogenesis of cellulitis is complex, and more work is needed so that novel therapies and vaccines can be developed to improve treatment and prevention of this disorder.

Molecular Typing of Beta-Hemolytic Streptococci from Two Patients with Lower-Limb Cellulitis: Identical Isolates from Toe Web and Blood Specimens

Intertriginous toe webs harboring cellulitis-causing bacteria constitute a risk factor for lower-limb cellulitis. Molecular typing of Streptococcus pyogenes and S. dysgalactiae subsp. equisimilis isolates from blood and toe webs of two cellulitis patients revealed identical strains for each species. This finding supports the role of toe webs as a potential site of entry for cellulitis pathogens.