Tinea Manuum

Dermatophyte infection of the palm, the finger webs and the dorsum of the hand. The commonest organism is Trichophyton rubrum, with T. interdigitale and Epidermophyton floccosum less often.

• It most often arises by autoinoculation from tinea pedis or onychomycosis, by scratching or touching infected feet or nails. It also follows contact with infected animals or soil.
• The classical "one hand, two feet" pattern is a unilateral palmar infection with bilateral foot involvement. Bilateral hand disease occurs but is less common.
• It is commoner in adult men, in people with diabetes, immunosuppression or sweaty hands, and in those who handle animals, soil or contaminated sports equipment.
• Untreated disease persists for years, and reinfection from the feet and nails is the usual reason for relapse.

• Hyperkeratotic (dry) form: diffuse fine, silvery or white scale over the palm, accentuated in the palmar creases, usually asymptomatic or mildly itchy. Often unilateral.
• Dorsal hand disease looks like tinea corporis: an annular, scaly plaque with an advancing raised edge and central clearing, sometimes with vesicles or pustules.
• Vesicular or inflammatory form: itchy vesicles at the edge of the palm and sides of the fingers, usually from zoophilic organisms.
• Nail involvement is common, with thickened, discoloured, crumbling nails.
• Differential diagnosis: chronic hand eczema, contact dermatitis, palmar psoriasis, keratoderma (hereditary or acquired), pompholyx, lichen planus, secondary syphilis, pityriasis rubra pilaris and squamous cell carcinoma in situ (a single non-healing patch).
• Complications: bacterial superinfection, nail dystrophy, tinea corporis elsewhere, and an id reaction (a symmetrical vesicular eruption on the sides of the fingers).

• Confirm with scrapings from the edge of the lesion in potassium hydroxide 10 to 20%, which show septate hyphae, followed by fungal culture for 2 to 4 weeks.
• This is important because tinea of the palm is frequently mistaken for eczema, and topical steroids make it worse and conceal the signs.
• Examine the feet, groin and nails for coexisting dermatophyte infection.
• Check HbA1c or fasting glucose in extensive or recurrent disease.
• Biopsy, with periodic acid Schiff staining, if the diagnosis stays uncertain after negative scrapings and the lesion does not respond.

• Treat all infected sites at once, including the feet and nails, or the hand will be reinfected.
• Topical therapy for mild localised disease, applied to the lesion and 2 cm of surrounding skin:
  • Terbinafine 1% cream once or twice daily for 2 to 4 weeks.
  • Clotrimazole 1% or miconazole 2% cream twice daily for 4 weeks.
  • Add urea 10 to 20% or salicylic acid 5 to 10% cream twice daily to thick scale, to improve penetration.
  • Continue 1 to 2 weeks after clearance.
• Oral therapy for hyperkeratotic, extensive, chronic or nail associated disease:
  • Terbinafine 250 mg orally daily for 2 to 4 weeks (child under 20 kg 62.5 mg daily, 20 to 40 kg 125 mg daily).
  • Itraconazole 100 mg orally daily for 2 to 4 weeks, or 200 mg daily for 1 week, with food (capsules).
  • Fluconazole 150 to 200 mg orally once weekly for 4 to 6 weeks.
  • Griseofulvin 500 mg to 1 g orally daily for 4 to 8 weeks is a second line option with lower efficacy.
  • Check liver tests if therapy extends beyond 4 weeks or if liver disease is present.
• Vesicular or acute inflammatory disease: potassium permanganate 1:10,000 or aluminium acetate 5% soaks for 10 minutes, 2 to 3 times daily, until weeping stops. Add flucloxacillin 500 mg orally 6 hourly for 7 days if there is bacterial superinfection.
• Hand care: dry the hands well after washing, avoid sharing towels, use gloves for wet work, and avoid scratching infected feet.
• Special groups:
  • Pregnancy: use topical clotrimazole or miconazole, and avoid oral therapy.
  • Children: use topical agents, and weight based oral terbinafine for extensive disease.
  • Renal or hepatic impairment: avoid terbinafine when creatinine clearance is below 50 mL/min or in active liver disease, and halve the fluconazole dose in significant renal impairment.
  • Immunosuppressed and diabetic patients: use oral therapy early and for longer.
• Treatment failure: re-confirm the diagnosis by culture, exclude eczema and psoriasis, check adherence, and identify untreated feet, nails or animal contacts.
• Follow up: review at 4 weeks. Refer to dermatology for persistent or resistant disease or doubtful diagnosis.