I'm miffed by responses employing empiric
therapy for a common condition that arises from
a myriad of etiologies, and amused by
the "secret weapon"comment. Presuming the lesion
has not arisen from a skin cancer (open wounds
not responding to therapy w/in 6 months =
biopsy), then determine the etiology BEFORE you
treat. This eliminates empiric therapy and
provides a basis for evidenced based medical
treatment.
In the case of macerated web spaces, how is this
accomplished? Well, my "secret weapon" is the
Wood's Light = color of florescence = etiology
ie. red = corynea bacteria minitismun = mycins;
green = pseudomonas = quinalones; white =
psoriasis or candida (ah...now there's the lone
scenario where 1 color has 2 potential
etiologies. Here, one is justified trying
empiric Fluconazole. If it resolves = candida,
if it doesn't, then likely psoriasis which can
later be confirmed by punch biopsy; lastly, a +
PAS = dermatophytes = fungicide. And...of
course, local topical therapy to reduce moisture
and maceration.
Don't you think it makes sense, and just a bit
easier to successfully treat something when you
actually know what it is? Has Wood's light has
fallen out of vogue? Why? Utilizing a UV light
source on a macerated web space clues the
clinician which etiology is responsible, thereby
avoiding weeks of unsuccessful empiric therapy
and patient dollar expenditures on various
medications not commensurate with etiology (just
like the dystrophic toenail post I made a few
weeks ago and the importance of nail unit
biopsy/culture for corroboration of suspected
diagnosis amidst a myriad of possible
differentials).
On balance, I think the treatment of a macerated
web space becomes pretty basic when you know
what's causing it, albeit the occasional red
herring.
Barry Mullen, DPM, Hackettstown, NJ,
yazy630@aol.com
