Toenail infection, Athlete's foot and Eczema all at once?

by Sal
(UK)

My poor 7 year old son has a fairly obvious nail skin fold infection on his right big toe (which is red, warm, swollen, and painful to touch, and I think he brought it about by biting his toenails!), but also what appeared at first to be Athlete's foot on the underside of the toes and balls of both of his feet, as well as what looks like Eczema on just his ankles (nowhere else on his body - when he's had Eczema flare-ups in the past it's usually across a much larger area in small patches and doesn't have a pattern).

I took him to the GP (who is good, and very supportive), and she said she believes the problem on the bottom of his feet is actually not Athlete's foot and is connected to the toenail infection, so she prescribed Flucloxacillin. Also, she gave him a Hydrocortisone cream for the Eczema on his ankles, and said she thought it might be connected, as it's isolated to just that area, which strangely perfectly encircles both of the ankles in a fairly thin line.

I wouldn't usually doubt the GP, but I feel a little confused about the diagnosis of the problem areas on the underside of my son's feet in particular. Perhaps we're both right, and it could be Athlete's foot with a complication of infection because of the toenail? What do you think it is?

Also, do you think that it's significant that the toenail infection, the problem on the underside of the feet, and the eczema on both ankles have all occurred simultaneously?

If it helps, we recently noticed that his shoes were letting in water (he now has new shoes of course) and his feet really smelled exceptionally bad after never having smelled even slightly bad before, with his socks drying hard due to whatever was on them. Also, unlike the patches on the ankles which itch intensely, the red areas under the feet don't seem to itch at all, and they only hurt mildly when he's walking down steps (so bending his feet up) but not on pressure.

Many thanks for your time.

RESPONSE

Hi Sal,

From the other side of the ocean it is difficult to tell exactly what is going on but I can offer some insight.

Yes, I do agree there is a high probability that the redness around his nails is from your son biting his nails and perhaps pulling at the loose ends which eventually lead to a paronychia or infection of the nail border. Having said that, typically soft tissue infections spread laterally, they do not jump to other parts of the foot. Additionally, depending on how bad the nail infection is, antibiotics alone may not do the job, a portion of the nail may have to removed. This would be the case if once he finishes the antibiotics, the nail infection returns.

I think the bigger issue here, as you pointed out, was the environment your son's feet were exposed to. Wearing wet shoes and socks opens the door to the athletes foot and eczema that he is suffering from. I would think that once you have removed that factor (which you have by buying him new shoes), his overall condition should start to improve.

In addition to the hydrocortisone cream you are using, I think a topical antifungal cream would also be very helpful. At a recent medical conference I attended, it was stated that the general thinking these days is "shotgun" therapy where you use multiple topical medications simply because in many cases it is hard to differentiate between eczema and athletes foot, particularly on the feet.

You will have to use the topical antifungal medication for at least four weeks, regardless of how well his feet begin to look, otherwise you can end up with what is known as a rebound phenomena where the area appears free of fungus, only to have it return because there is still active fungus in the skin and the topical medication has been stopped too soon.

I would also recommend washing his feet daily in tea tree oil soap which has antifungal properties in it and will help rid the fungus from the skin.

The only other point worth mentioning is you will have to rule out erysipelas which is a rash caused by a strep infection and can mimic the run of the mill eczemas. I mention this just in case the eczema does not respond to topical medication.

Going forward, make sure your son's feet are kept in a dry environment and work on the notion that biting his nails, is not the best thing that he can be doing for himself.

Marc Mitnick DPM
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