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Pedal Interdigital Condylomata Lata

A Rare Sign of Secondary Syphilis


TED ROSEN, MD, AND HEIDI HWONG, BS

From the Department of Dermatology, Baylor College of


Medicine, Houston, Texas

Background: Condylomata lata of the toe webs are uncommon manifestations of secondary syphilis. Considering the
recent decline in the incidence of syphilis in the United States,
such lesions are likely to present infrequently. In some cases,
this phenomenon may be the only physical sign of syphilis;
therefore, it is important that a high index of suspicion is
maintained when evaluating toe web lesions in patients at
epidemiologic risk for syphilis.
Goals: A case of secondary syphilis presenting solely with
interdigital condyloma lata in the toe web spaces is reported,
and similar cases reported in the literature are reviewed.
Study Design: This article documents the diagnosis of secondary syphilis based on a positive serology in conjunction
with the development of interdigital condyloma lata as the only
physical finding suggestive of lues.
Results: The latter lesions resolved after appropriate, adequate antibiotic therapy.
Conclusions: A case of condylomata lata of the toe webs
without other pertinent physical findings is presented. Analogous to lesions typically seen in the anogenital region, moist
exophytic toe web plaques may represent condyloma lata and
thereby be a sign of secondary syphilis. The differential diagnosis includes tinea pedis, erythrasma, macerated corns, verrucae, and several tropical mycoses (chromomycosis,
mycetoma).

lis. Condylomata lata of the toe webs are uncommon manifestations of secondary syphilis that have been highlighted
infrequently in recent medical publications. In the last 60
years, there have been only five published reports in the
English language that describe condylomata lata of the toe
webs in a total of 20 patients.2 6 In an effort to increase
awareness of this unusual finding, a case of interdigital
condylomata lata is presented and various other parameters
pertaining to these lesions are analyzed. Previously reported
cases are also reviewed.

Case Report
During routine blood screening, a 42-year-old black man
was found to have a positive rapid plasma reagin result in a
titer of 1:128. The patient was subsequently referred to a
dermatology service for evaluation. The patient admitted to
multiple episodes of unprotected sexual intercourse with
anonymous partners within the preceding 6 months and
gave a vague history of a transient, painless penile lesion of
approximately 2 months duration, but was otherwise
asymptomatic. Physical examination disclosed oozing
papulonodular lesions located in interdigital web spaces
between the third and fourth and the fourth and fifth toes on
one foot, and in the webspace between the third and fourth
toes on the other foot (Fig. 1). Results of darkfield examination of the serous exudate obtained from one of these
lesions were positive, confirming the diagnosis of secondary syphilis. The remainder of the physical examination was unremarkable, and screening HIV serology was
negative. One month after treatment with intramuscular
benzathine penicillin 2.4 million U, the pedal lesions had
entirely resolved, and the rapid plasma reagin titer had
decreased to 1:4.

THE MULTIPLE MANIFESTATIONS of syphilis often


mimic many other diseases; however, there are distinctive
findings for each of the three stages of syphilis. The classic
physical findings of secondary syphilis (macular, maculopapular, and papular eruptions of the trunk, palms, and soles
of the feet; oral mucosal patches; moth-eaten alopecia;
typical condylomata lata) were well recognized by earlier
generations of physicians because of the relatively high
incidence of syphilis. The incidence of primary and secondary syphilis is at its lowest point since reporting began in
1941,1 and todays physicians have considerably less experience with the manifold presentations of secondary syphi-

Reprint requests: Ted Rosen, MD, Department of Dermatology, F840,


Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030. E-mail:
VampireTed@aol.com
Received for publication June 7, 2000, revised August 2, 2000, and
accepted August 8, 2000.

184

185

PEDAL INTERDIGITAL CONDYLOMATA LATA

Vol. 28 No. 3

Discussion

Fig. 1. Darkfield-positive moist plaques (condylomata lata) between the third and fourth toes of the right foot.

TABLE 1.

Previously Reported Cases of Toe Web Condyloma Lata

Demographic Data*
20-year-old
34-year-old
26-year-old
28-year-old
39-year-old
22-year-old
24-year-old
28-year-old
19-year-old
23-year-old
23-year-old
22-year-old
16-year-old
25-year-old
28-year-old
47-year-old
47-year-old

Condylomata lata are extremely infectious, moist papules


commonly seen in secondary syphilis. These lesions often
occur in areas of opposing skin surfaces associated with
heat, moisture, and friction (e.g., the genitalia, perianal area,
and axilla). Less frequently, these lesions may occur in toe
webs. Gram-negative toe web infections and tinea pedis
may predispose patients to the development of condylomata
lata. In 1940, Thomas and Bluefarb described six patients
who were affected by both chronic dermatophytosis of the
toe webs and interdigital condylomata lata.2 It has also been
observed that interdigital condylomata lata have a propensity for involvement of the lateral toe webs, particularly the
interdigital spaces between the third and fourth and the
fourth and fifth toes.6
There are 20 previously reported cases of condylomata
lata of the toe webs in the English literature from 1940 to
1996, 17 of which contain detailed demographic and clinical descriptions. (Table 1) These detailed cases involved
patients who were described as black (71%) or white
(29%).2 6 The greater frequency of black patients in published cases of interdigital condylomata lata may simply
correspond to the disproportionately higher rate of syphilis
in this population, or may reflect a different tissue response
to syphilis in this racial or ethnic group, as has been noted
with the annular syphilid.
According to the literature, condylomata lata may be
found in single, multiple, or all web spaces. More than half
(53%) of the previously reported patients with available
descriptions of physical findings had involvement of only
one toe web. Therefore, it is important to maintain a high

BM
WM
WM
WM
BM
BW
BW
BM
BW
WW
WW
BW
BG
BM
BM
BM
BM

Number of Toe
Web Lesions

Other Cutaneous Lesions

Reference
Number

1
2
2
2
1
1
2
2
1
2
1
1
1
1
2
1
2

Femoral bubo, red throat


Papules in throat
Multiple scrotal papules
Multiple cutaneous lesions
Multiple cutaneous lesions
Multiple cutaneous lesions
Truncal macules; alopecia
Multiple cutaneous lesions
Generalized papulosquamous eruption
Multiple cutaneous lesions
Palmar macules
Macules on forearm; cervical erosion
Perianal condylomata
None
Annular lesions of the face
None
Brown scaly papules

2
2
2
3
3
3
3
3
3
3
3
3
3
4
5
6
6

*No demographic data for three of six patients reported in Arch Dermatol Syphilol, 1940.
BM black man; WM white man; BW black woman; WW white woman; BG black girl.

186

ROSEN AND HWONG

index of suspicion even with an apparently minimal number


of lesions. In contrast, 47% of reported patients presented
with involvement of multiple toe web spaces.
Of the cases with interdigital condylomata lata, 88%
involved other cutaneous lesions more commonly seen with
secondary syphilis, such as a generalized maculopapular
eruption. However, in a few cases, including the one reported herein, condylomata lata of the web spaces were the
only cutaneous manifestation. Thus, the absence of a typical
truncal eruption, mucous patches, alopecia, or palmar-plantar lesions does not reliably exclude syphilis.
As mentioned previously, interdigital condylomata lata
are infrequent findings in syphilis. Such lesions carry an
extensive differential diagnosis, including interdigital tinea
pedis, erythrasma, macerated corns, ulcerated verruca, verrucous carcinoma, chromomycosis, mycetoma, and other
fungal and gram-negative toe web infections. Thus, when
moist interdigital lesions of the foot fail to respond to the
typical effective therapy for a presumed diagnosis, a high
index of suspicion for condylomata lata of secondary syphilis is needed. Because these lesions are moist and contain
abundant spirochetes within lesional exudate, darkfield examination, if available, is diagnostic. Serologic test results
for syphilis are also expected to be positive.
A new case of interdigital condylomata lata is presented

Sexually Transmitted Diseases

March 2001

with a review of the literature. Similar to most patients whose


cases were previously reported, this patient is also black;
however, the significance of ethnicity in relation to condylomata lata of the toe webs needs more study. Although this
patient had multiple toe web lesions, no other manifestations of
secondary syphilis were present, and positive darkfield examination results confirmed the diagnosis. The diagnosis of condylomata lata should be considered when evaluating toe web
lesions, particularly if lesions are unresponsive to typical therapy, because these may be the only manifestation of a disease
with known effective treatment.

References
1. Centers for Disease Control and Prevention. Primary and secondary
syphilisUnited States, 1998. MMWR Morb Mortal Wkly Rep 1999;
48:873 878.
2. Thomas EW, Bluefarb SM. Early syphilitic lesions mistaken for dermatophytosis. Arch Dermatol Syphilol 1940; 42:1114.
3. Dexter HT. Interdigital infectious syphilitic lesions simulating dermatophytosis. Arch Dermatol 1951; 63:581585.
4. Minkin W, Landy SF, Cohen HJ. An unusual solitary lesion of secondary syphilis. Arch Dermatol 1967; 95:217.
5. Hira SK. Condylomata lata of the toewebs: a case report of an unusual
manifestation of syphilis. Sex Transm Dis 1984; 11:167168.
6. Templeton SF. Condyloma latum of the toe webs: an unusual manifestation
of secondary syphilis. A report of two cases. Cutis 1996; 57:38 40.