Ronda, thank you so much for bringing us your case. In addition to topical recommendations, I have several inquiries:
1. How is nutrition?
2. This appears more venous in nature secondary to edema and superficial varicosities--is this accurate?
3. If there is venous disease, has she had any studies that would indicate her disease is amenable to intervention? Any concerns for arterial compromise?
4. If venous, is compression utilized?
5. Who changes her dressing, and what is her social/living situation?
6. Does she have any allergies?
7. What is being used for wound cleanser/overall foot cleanser?
8. Referencing the recent culture, was this taken due to stalled progress, or local or systemic signs/symptoms?
9. How is overall hygiene?

Preliminarily without above clarifications, my thoughts for topical recommendations only would include cleansing the wound and foot with Vashe, leaving vashe soaked gauze on the wound for 10 minutes if possible prior to dressing reapplication. If only able to accomplish this in clinic, that is acceptable. I would recommend using a broad spectrum antimicrobial like iodoflex/iodosorb, (with foam or other to separate the afflicted digits) which depending on exudate level, may be left intact for several days. You may also paint normal betadine between the toes to discourage fungal growth.

If she is wearing socks and no other secondary dressing is used over a gauze wrap, you might ensure she is laundering the socks appropriately and not re-using them. Also, ensure clean socks are applied daily if possible.

Hi Ronda,
Samantha gave great advice. Lamisil AF - an OTC product - can also be placed between the toes to treat fungal growth. Another alternative to the hypochlorous products (e.g. Vashe) if they are not on your formulary would be using 1/4% Acetic acid which also has antifungal properties and could be less expensive.

Thank you sooooo much for your input-
Yes a venous component - only compression used is ace.
Nutrition is good, living situation is very good. She does smoke 2-3 cigs per day.
Allergies: Medrol pak, sulfa, Zithromax, Macrobid- they have been trying many antibiotics on her, but not changing the topical treatment. She goes to a wound center, and we see her in home health-
I was asked to evaluate in home health due to poor progress. I have access to VASHE, and can get the iodosorb also, love the Lamisil AF
Really appreciate the opportunity to gain input your input on this case.
Thank you!