"Paani Mein Chalne Ke Baad Pairon Mein Khujli" — Foot Infection in Monsoon

"Bhaiya, paani mein chalne ke baad pairon mein khujli ho rahi hai."

We hear a version of this every week from late July, almost always from the same people: delivery riders, men who open a shop at nine, students walking the last stretch to college, anyone whose commute crosses a road that is now a canal. They arrive after two or three weeks of it, when the itching between the toes has become raw skin, or a small cut has started to look angry.

Athlete's foot — tinea pedis — is a fungal infection of the skin between and under the toes, and it is the single commonest thing we find. Common is not an overstatement: the NIH's StatPearls clinical reference records that "Tinea pedis may affect approximately 10% of the total population". Almost none of it comes from one heroic wade through knee-deep water. It comes from the ordinary version — feet wet from eight in the morning, socks that never dried, shoes worn again still damp inside.

Paani mein chalne ke baad pairon mein khujli — what is actually in that water?

Water standing on an Indore road in August is not rain water. By the time it is deep enough to walk through, it is rain mixed with overflow from choked drains, road dirt, mud, and the urine of street animals and rodents washed in from upstream.

That water also hides things — broken glass, a nail in a plank, an open drain cover. People feel a small sting, think nothing of it, and find the cut at night. A cut made under that water is contaminated at the moment it is made.

Even so, most people who wade are not harmed by the water itself. What harms them is how long the skin stays wet afterwards.

Why wet feet turn into a foot infection in monsoon

A foot infection in monsoon is a barrier problem before it is a germ problem. Healthy skin is a sealed barrier and it depends on being reasonably dry. Keep it soaked for hours and it macerates — pale, soft and wrinkled, the way fingertips go in a long bath. Macerated skin tears easily and stops keeping things out.

The spaces between the toes suffer most, because they hold moisture and never see the air inside a closed shoe. Add the warmth of a foot in a wet sock and you have what fungi prefer: warm, dark and damp, eight hours at a stretch, daily for a month.

So the sequence is not dirty water causing infection. It is prolonged wetness weakening the skin, and then whatever is present — fungus from the shoe lining, bacteria from the road or the skin itself — getting through a barrier that has stopped working. The same logic explains the wet-weather ear trouble we see in people who ride in the rain, in why a wet helmet leads to an itchy ear.

Which four problems do we see most in our OPD in Indore?

Four diagnoses account for nearly everything that walks into our Indore OPD with a monsoon foot, and they are worth telling apart because two are trivial and two are not. The order below is also the order in which one problem leads to the next: cracked skin between the toes is the doorway through which the serious ones arrive. StatPearls makes that link explicit for cellulitis, advising that "careful evaluation should be made to look between the patient's toes for fissuring or tinea pedis".

Athlete's foot. Fungal infection between the toes, usually the outer two first. White, soggy, peeling skin, a crack that stings, itching worst on taking the shoes off. Left alone it spreads across the sole and into the toenails, which are far harder to clear.

Fungal infection of the groin and skin folds. An itchy, ring-shaped rash with a raised edge, in the groin, under the waistband or under the arms. Usually the same fungus, carried up from the feet by a towel, and kept alive by clothes that never dry properly.

Cellulitis. A bacterial infection spreading in the deeper skin, usually entering through a crack between the toes or a small wound. The area turns red, hot, swollen and tender, the redness spreads outward over hours, and there may be fever and shivering. StatPearls counts over 14 million documented cases in the United States annually, and records that it recurs in about 8% to 20% of patients each year. This is not a home problem.

The small wound that becomes serious. A shallow cut from something under the water, cleaned casually, covered by a damp sock, walked on for three days. Most heal. The ones that do not usually belong to people who could not feel them.

If you have diabetes, please read this section twice

Diabetes changes everything above in seriousness, for three reasons that compound each other. The first is sensation. Long-standing diabetes damages the nerves in the feet, gradually enough that most people never notice it happening. Pain is the alarm that makes anyone else pull the foot back, look at it and clean it. Without that alarm, a nail can go into the sole and be found that evening as a stain on the sock. We have seen wounds walked on for a week because they never hurt.

The second is circulation. Blood supply to the feet is often reduced, so healing is slower. The third is that raised blood sugar itself makes infection easier to acquire and harder to control. Put the three together and a small monsoon wound in a numb foot can become a deep infection in days, without the pain that would have brought anyone else in.

So the rules are different, and they are not negotiable. Avoid wading if you possibly can, and do not walk barefoot indoors either. Look at both feet every night, soles included — use a mirror or ask someone at home, because you cannot rely on feeling it. Do not soak the feet, do not use very hot water, and do not cut corns or hard skin yourself. Any wound, blister, crack or colour change on a diabetic foot this season is urgent, not something to watch for a week.

The steroid cream trap — the commonest correction we make all monsoon

Steroid-containing creams are the single commonest thing we correct in the monsoon months, and the trap works the same way every time. Someone has itching between the toes or a ring-shaped patch in the groin. A shop, a neighbour or an old prescription supplies a cream — usually one of the popular combination tubes containing a steroid. For two or three days it is wonderful. The itching stops, the redness fades, everyone is satisfied. Then it gets worse.

The reason is well documented. StatPearls, the NIH-hosted clinical reference, puts it this way: "Tinea incognito is another possible complication of steroid administration where the typical presentation of tinea is masked, and diagnosis is delayed."

In practice that means the neat ring loses its edge and becomes a vague patch that no longer looks like anything recognisable. The skin thins and discolours, and the diagnosis becomes harder for the next doctor to make. What would have been a few weeks of proper antifungal treatment turns into months. Plainly: a cream that stops the itch is not the same as a cream that treats the infection. Getting the diagnosis right at the start costs one appointment; getting it wrong costs a season.

"A cream that stops the itch is not the same as a cream that treats the infection. Dry properly between the toes every day, and get an itchy rash identified once instead of working through steroid tubes from the shop." — Dr. Arpit Maurya, MBBS, MS (Orthopaedics)

Leptospirosis — worth mentioning to a doctor after wading

Leptospirosis is a bacterial infection carried in the urine of infected animals, especially rodents, which washes into flood water and enters through broken skin or skin that has been soaked for a long time. The CDC estimates that "An estimated 1 million cases occur globally each year, resulting in nearly 60,000 deaths", and notes that cases rise after flooding, when people have to wade through contaminated water. It does not happen to everyone who wades, and we are not raising it to alarm anyone.

What matters is the timing and the telling. The CDC records that it "generally takes 2-30 days to get sick" after contact, and warns that "Many of these symptoms can be mistaken for other diseases." So if you develop a flu-like illness — fever, headache, severe muscle aching often worst in the calves, sometimes red eyes — within days to a couple of weeks of wading, say so to the doctor. That one sentence changes what gets tested. Fever has several explanations this season, which is why we have set out separately how to tell viral fever from dengue at home.

Ghar pe abhi kya karein — what to do at home right now

For anyone whose feet get wet daily, the routine is simple: wash and dry the feet properly on arrival — especially between the toes — change out of wet socks, alternate two pairs of shoes so each dries a full day inside, cover any cut with a waterproof dressing before going out, and do not use a shop-bought cream on an itchy rash.

• Wash and dry properly on arrival. Clean water and soap, then dry thoroughly — pairon ki ungliyon ke beech achhi tarah sukhayein. Those thirty seconds between the toes are the most useful habit on this page.
• Alternate your footwear. Shoes need a full day to dry inside. Two pairs on alternate days beats any powder or spray.
• Never sit in wet socks. Carry a dry pair. Where work allows, open washable footwear beats closed shoes that stay wet.
• Cover any cut before you go out with a waterproof dressing, and clean it with soap and clean water as soon as you are home.
• Do not use a cream from a shop or a relative for an itchy rash. Get it identified once instead.
• Keep the same discipline with clothes, since damp trousers carry the same fungus to the groin and waistline. This is also the week to clear standing water at home, for the reasons in our guide to dengue prevention in your own building.

When should you get a foot or skin problem looked at in Indore, before it spreads?

Most of this is easy to settle when it is seen early. Athlete's foot caught in its first week is a short treatment; caught in its second month, after two steroid creams, it is a long one. A cut cleaned and dressed on day one is rarely a problem. The same cut in a numb foot, found on day six, sometimes is.

We see patients Monday to Saturday, 6 to 8 PM. You can message the clinic on WhatsApp, call 7869709075 for an evening slot, or find timings on drhealthcare.in. If you have diabetes, bring your recent sugar reports and come the same week rather than watching a wound at home.

Questions patients ask us