8/21/2019 Pedal Interdigital Condylomata Lata a Rare Sign.11

1/3

Pedal Interdigital Condylomata Lata

 A Rare Sign of Secondary Syphilis

TED ROSEN, MD, AND HEIDI HWONG, BS

 Background:  Condylomata lata of the toe webs are uncom-mon manifestations of secondary syphilis. Considering therecent 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 ismaintained when evaluating toe web lesions in patients atepidemiologic risk for syphilis.

Goals:   A case of secondary syphilis presenting solely withinterdigital 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 sec-ondary syphilis based on a positive serology in conjunctionwith the development of interdigital condyloma lata as the onlyphysical finding suggestive of lues.

 Results:  The latter lesions resolved after appropriate, ade-quate antibiotic therapy.

Conclusions:   A case of condylomata lata of the toe webswithout other pertinent physical findings is presented. Analo-gous to lesions typically seen in the anogenital region, moistexophytic toe web plaques may represent condyloma lata andthereby be a sign of secondary syphilis. The differential diag-nosis includes tinea pedis, erythrasma, macerated corns, ver-rucae, and several tropical mycoses (chromomycosis,mycetoma).

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, maculo-

papular, 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 second-

ary syphilis is at its lowest point since reporting began in

1941,1 and today’s physicians have considerably less expe-

rience with the manifold presentations of secondary syphi-

lis. Condylomata lata of the toe webs are uncommon man-ifestations 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 onone foot, and in the webspace between the third and fourth

toes on the other foot (Fig. 1). Results of darkfield exami-

nation of the serous exudate obtained from one of these

lesions were positive, confirming the diagnosis of sec-

ondary syphilis. The remainder of the physical examina-

tion 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.

Reprint requests: Ted Rosen, MD, Department of Dermatology, F840,Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030. E-mail:

VampireTed@aol.comReceived for publication June 7, 2000, revised August 2, 2000, and

accepted August 8, 2000.

From the Department of Dermatology, Baylor College of Medicine, Houston, Texas

184

8/21/2019 Pedal Interdigital Condylomata Lata a Rare Sign.11

2/3

Discussion

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 toewebs. 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 propen-

sity 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 clini-

cal 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 pub-

lished 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 highFig. 1. Darkfield-positive moist plaques (condylomata lata) be-

tween the third and fourth toes of the right foot.

TABLE 1. Previously Reported Cases of Toe Web Condyloma Lata

Demographic Data*Number of Toe

Web Lesions Other Cutaneous LesionsReference

Number

20-year-old BM 1 Femoral bubo, red throat 234-year-old WM   2 Papules in throat 226-year-old WM   2 Multiple scrotal papules 228-year-old WM   2 Multiple cutaneous lesions 339-year-old BM 1 Multiple cutaneous lesions 3

22-year-old BW 1 Multiple cutaneous lesions 324-year-old BW 2 Truncal macules; alopecia 328-year-old BM   2 Multiple cutaneous lesions 319-year-old BW 1 Generalized papulosquamous eruption 323-year-old WW   2 Multiple cutaneous lesions 323-year-old WW 1 Palmar macules 322-year-old BW 1 Macules on forearm; cervical erosion 316-year-old BG 1 Perianal condylomata 325-year-old BM 1 None 428-year-old BM   2 Annular lesions of the face 547-year-old BM 1 None 647-year-old BM 2 Brown scaly papules 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.

Vol. 28  ●  No. 3   185PEDAL INTERDIGITAL CONDYLOMATA LATA

8/21/2019 Pedal Interdigital Condylomata Lata a Rare Sign.11

3/3

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 re-ported 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-plan-

tar 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, ver-

rucous 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 highindex of suspicion for condylomata lata of secondary syph-

ilis is needed. Because these lesions are moist and contain

abundant spirochetes within lesional exudate, darkfield ex-

amination, if available, is diagnostic. Serologic test results

for syphilis are also expected to be positive.

A new case of interdigital condylomata lata is presented

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 condylo-

mata 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 exam-

ination results confirmed the diagnosis. The diagnosis of con-dylomata lata should be considered when evaluating toe web

lesions, particularly if lesions are unresponsive to typical ther-

apy, 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

syphilis–United States, 1998. MMWR Morb Mortal Wkly Rep 1999;48:873–878.

2. Thomas EW, Bluefarb SM. Early syphilitic lesions mistaken for der-

matophytosis. Arch Dermatol Syphilol 1940; 42:11–14.3. Dexter HT. Interdigital infectious syphilitic lesions simulating dermato-

phytosis. Arch Dermatol 1951; 63:581–585.

4. Minkin W, Landy SF, Cohen HJ. An unusual solitary lesion of second-ary 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; 11:167–168.

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.

186   Sexually Transmitted Diseases   ●   March 2001ROSEN AND HWONG