Is this a severe presentation of a fungal infection?

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My client presents with blisters 1or 2mm and up to 15mm across on the plantar surface from the toes to the heel. Moccasin redness with some itching. The blisters are deep and penetrating and filled with yellowish/green fluid. there is aslight odour.

Her GP initially prescibed topical steroid cream which made no difference. Eventually sent to Dermatologist who diagnosed a hereditary condition (unfortunately she cannot remember what he said) but as the lady concerned is 85 years old is this likely?

I have been de-roofing, flushing with sterile saline and covering with lyofoam to encourage healing with some success but as soon as one heals another appears on the other foot or several at a time!

I have been encouraging her to apply Lamisil which does help with the itching.

I found some pictures on the internet which looked similar and these were deccribed as a fungal infection but I have been unable to locate them again.

Has anyone come across this form of blistering or infection and found a suitable treatment?

 

:welcome:

If it is a fungal infection it sounds like secondary bacterial involvement as well- my money would be on ulcerative tinea until shown other evidence.

If you could post a picture it would be helpful, but I would say time for scrapings and fluid samples if not done already.

There are conditions like bulous pemphigoid (or one of the other pemphigoids) which do occur in the 7-8th decades and can affect plantar surface although I'd be surprised if it was isolated only to here.

Hope that helps until someone who really knows something comes along
Ian

 

Get in touch with the Dermatologist and check what DDX it has, could be Pustular psoriasis, Ive gat and old guy with similar problems and even with steroid cream etc it onty helps a bit, doe sit effect the hands/ only one hand?

 

Difficult to offer a dermatological opinion without a picture. However, your description of the lesions sound very much like the vesico-pustules associated with the dermatophytes tri- mentagrophytes and/or Epidermophyton fluccosum. If the topical terbinafine (Lamisil) is improving symptoms, then this would also suggest pathological fungi. Application of topical steroid will only exacerbate the condition, if it is tinea, as this will mask inflammation and the fungus will actually proliferate.

The other suggestions that there may be secondary bacterial infection present are reasonable and I would also take skin scrapings for culture. This could be a case of `two feet, one hand syndrome` ie tinea.

Once you have a definitive diagnosis from the microbiology and culture report, you can then formulate an appropriate treatment plan, which will probably entail a combination prescription of both a topical and an oral anti-fungal.

Cheers,
Bel

 

Thank you all for your very helpful comments.

The GP has already taken samples for analysis for fungal and bacterial infection but both were negative/ inconclusive so basically he washed his hands of her! The consultant dematologist did not offer any treatment because he was convinced it was an hereditary condition with no known treatment. It has been left to me to try and help this lady as much as I can without access to what might be appropriate treatment.

I think you are confirming my own suspicions that it probably is fungal with an element of bacterial. I checked out your differential diagnosis but none fit the symptoms.

My next move will be to contact her GP and suggest an oral terbinifine and suitable Ab might be an appropriate course.

Unfortunately I am new to P.Arena and did not think to take photos before deciding to ask for help but I am grateful for your support. When she comes in next week I will get some photos and let you know the progress.


Many thanks

 

Lichen planus also has a rare bullous presentation. Worth a look since scrapings were negative. Look at deep systemic fungal infections, Blastomycosis etc, as they would partially respond to topical but won't completely clear. Photos are helpful, derm is visual.
Sarah

 

I think Ive got a Chromo Blasto Mycosis case im looking into it now however very non-compliant pt. Gonna get a sample and do some self microscopy in the lab....MMMMMMMhhhhwwwwwwaaaH!

 

My client has huge deep blisters on the sole of the foot or the margins of the heel and typical moccasin redness around the foot . There are no presentations of the infection speading any where else. As the skin is so thick the blisters do not break and just fill up penetrating deeper into the dermis.

Anti-fungals keep cropping up as a treatment but is itraconazole more effective than terbinifine in eliminating fungal infections if isolation of the cause is difficult?

 

Again, all advice is pure speculation without pictures.....but (isn`t there always?) remember; common things occur commonly, horses and hooves, etc, etc....

Just because a GP took tissue samples which were inconclusive, I would not rule tinea out, just yet. GP`s, in general, are not trained in obtaining either sufficient amounts nor appropriate, ie where the infection is active, skin scrapings. IMO, it would be worth taking your own sample and sending it directly to the path lab.

Itracanazole is fungistatic, it relies on skin turnover to work by inhibiting fungal reproduction. Whereas, clotrimazole and terbinafine are fungicidal, they destroy the fungus and are, therefore, more potent. However, fungistatics are sometimes a more appropriate course of treatment, particularly where there is no nail involvement. That said, at the end of the day, the choice of anti-fungals will rest mainly with the GP.

You may find this of interest;

 

Hi,
yellowish green fluid from blisters. ill put my money on Pseudomonas infection. this gram -ve bacteria Can infest secondary to TInea. Venegar is used to clean Pseudomonas infected lesions, Rx. Norfloxin 500 mg or Ciplox 500 mg TID.

Heriditary cause - Epidermolysis Bullosum. Ask ur pt if she ever had such spontaneous blistering in the past. ive seen this in children. In this the blister fluid was clear. Thats what makes me wonder if it may be infected with pseudomonas since ur pt has greenish fluid.

Try venegar wash, if it clears ur on right track. i have no clue why venegar and how it works.

hope this helps

 

All these replies are perfectly reasonable suggestions for treatment of specific pathologies. However, I would strongly advise you not to treat until you have obtained a definitive diagnosis yourself.

If you wish to continue podiatric treatment for this patient then you need to contact the dermatologist who diagnosed the hereditary disorder, in order to formulate an appropriate treatment plan. Second guessing any pathology and subsequent inappropriate treatment will leave you wide open to litigation and rightly so.

Sorry if I come across a bit terse today, I`m more concerned with appropriate diagnostic tests and treatment for my daughter at the moment.

 

Many thanks to all for your responses. That was a particularly helpful link to the article in Podiatry Now. It could almost be describing the events for my client. The blisters are somewhat larger but the description is same and she has also experienced redness on her hands.

She has a history of mild mycotic infection going back to 2007 for which I have been encouraging the use of topical antifungals.

Since last week she has been using Lamisil daily and the difference is quite marked. Although there are still blisters under the 4/5 th toes and on the heel of the left foot the large blisters debrided last week are drying out and none have appeared on the right foot.

As this is my first picture posting I hope I have done it correctly. The photographer needs some lessons!

 

Hmmmm.... The pustules look rather like pustular psoriasis (although difficult to put money on it, as the pics are a little out of focus). They are indeed larger than the average vesico-pustules usually associated with plain ol` tinea. Then again, it is relatively common for dermatophytes to proliferate in any skin which is compromised, which does include psoriasis.

It`s good that topical Lamisil is alleviating symptoms, but if the localised rubour remains, I would be thinking Ps.


Hope that helps!

Bel

 

It certainly looks more like pustular psoriasis than a frank mycotic condition and the Dermatologists opinion seems to confirm this - always worthwhile trying to make contact because patients so frequently mishear or get confused. As Bel has mentioned, secondary infection is always a possibility. Despite the poor tissue condition, it might be worth trying a short course of a Vit/steroid cream such as Dovobet.

All the best

Bill Liggins

 

Hi Bel,
Working on my derm, whre have i gone wrong? Since the blister fluid was green i thought Pseudomonas infec (sec to Tinea). seeing the photos i would agree plantar pustuloses (well demarcated lesions, erythematous base, pus filled papules with dried off skin flakes, plantar distribution).

advise plzz

 

Hi Dave,

You didn`t go wrong! It is near impossible to even begin to suggest diagnosis of a dermatological complaint without pics. Your suggestion was perfectly rational with the information provided at the time.

Whilst it`s true that pseudomonas bacterium manifests a green hue (caused by pyoverdin), it is usually found in singular moist, compromised wounds, such as; burn injuries, ulcers and inter-digitally as a secondary infection of tinea in addition to nails. It`s the maceration, or occlusion, of these skin lesions that can lead to secondary bacterial infection, pseudomonas being such one. Pseudomonas is an evolving infection, in that deep erosions and tissue necrosis usually occur before the condition is diagnosed correctly. Pain and fever are also usually present. This wasn`t the case with Sussex Hen`s pt. This is most likely palmoplantar psoriasis (or palmoplantar pustulosis, as some dermatologists prefer to call it).

The serum-like exudate or pus, which contains glycoproteins, in pustular psoriasis is sterile and these are often referred to as `salmon patches` (not entirely sure why. Looks nuffin` like a fish...) The exudate is generally yellow, but can look greenish, but an altogether different green to darker coloured pseudomonas......which is different to Lord Percy`s Nugget of Purest Green;

http://www.youtube.com/watch?v=Qt8a7wxMJW4

Hope That Helps!

Bel

 

Looked at several websites at the symptoms for pustular psoriasis and they don't seem to fit what I see.

Sorry one of the pictures is slightly out of focus but what is shown on the other two is the dried margins of the blisters that have been debrided. If you follow the edge of the dried skin you will see how large the blisters were. They do not appear initially as discreet vesicle which coalesce, they just get bigger as the fluid inside expands.

There is no scaling of the skin. The lady in question has a dry skin and with a pad of shallow callus over the mets always because of the retracted toes.

It was back in Oct that I initially noticed redness and plaques of dry skin and thought myself it may be psoriasis but there was a lot of redness interdigitally and this was followed by blisters under B1st and med arch. Topical antifungal was used and the symptoms resolved only to reappear in March. This cleared up again and at this point she saw the dermatologist so really there was nothing for him to see so his diagnosis was based on my clients explanation.

It was while I was unavailable in May the symptoms flared up with avengeance to what I see now. She had been using the topical steroid cream prescibed by her GP and this is known to allow a mycotic infection to proliferate.

It would probably be appropriate to redo the tests but unfortunately I do not have the facilities to these myself and they are anyway notoriously unreliable for confirming the presence of fungal disease and would find myself no further forward. I will contact her GP to see if he will do this or re -refer to the dermatologist.

Many thanks for all your posts. It has been extremely helpful and supportive.

 

Hi Sussex Hen,

If you have a 15 blade and some dark paper, you can take the scrapings and send them directly to your local NHS path lab.

Not sure why you would want to re-refer to the dermatologist if she has already obtained the diagnosis of a hereditary disorder from them. Why can`t you just ask the dermatologist what the diagnosis is?

Cheers,
Bel


BTW, I`m a `Sussex chick ` too

 

Noticed you said chick and not hen!!!!!!!!!!

 

That`s cos I`m a young `un.....as you know, Steve

 

So chick not foul - sorry fowl!!!! - ok got it now :0)