What is the treatment for a fungal infection of the hands?

Treatment of Fungal Infection of the Hands

For dermatophyte infections of the hands (tinea manuum), topical antifungal therapy with azoles or allylamines for 2-4 weeks is the first-line treatment, while Candida infections require itraconazole 200 mg daily for at least 4 weeks as first-line systemic therapy, with fluconazole as an alternative. 1

Determining the Type of Fungal Infection

The causative organism must be identified before initiating treatment, as dermatophytes and Candida species require different therapeutic approaches 1, 2:

• Dermatophyte infections (tinea manuum): Look for dry, scaly patches with raised borders, often unilateral presentation, and involvement of palmar surfaces 2, 3
• Candida infections: Typically present with moist, erythematous interdigital spaces, paronychia, or involvement in patients with occupational water exposure (e.g., dishwashers, healthcare workers) 1, 4
• Confirm diagnosis with potassium hydroxide (KOH) preparation of skin scrapings showing hyphae (dermatophytes) or budding yeasts (Candida) 2, 3

Treatment for Dermatophyte Infections (Tinea Manuum)

Topical Therapy (First-Line)

Fungicidal allylamines are preferred over fungistatic azoles because they kill fungi rather than just inhibiting growth, allowing shorter treatment courses and reducing recurrence rates 5:

• Terbinafine cream: Apply once daily for 1-2 weeks 5, 3
• Naftifine or butenafine cream: Apply once daily for 1-2 weeks 5
• Alternative azoles (if allylamines unavailable): Miconazole, clotrimazole, or ketoconazole applied twice daily for 2-4 weeks 2, 4, 3

Continue treatment for at least one week after clinical clearing to prevent recurrence 3

Systemic Therapy (For Extensive or Resistant Cases)

When topical therapy fails or infection is widespread 4, 3:

• Terbinafine 250 mg daily for 2-4 weeks 1
• Itraconazole 200 mg daily for 2-4 weeks 2
• Griseofulvin 500 mg daily (less preferred due to longer treatment duration): 4-8 weeks 6, 2

Treatment for Candida Infections of the Hands

Without Nail Involvement

Itraconazole is the first-line systemic treatment for Candida hand infections 1:

• Itraconazole 200 mg daily for minimum 4 weeks 1
• Alternative: Fluconazole 200-400 mg daily for minimum 4 weeks if contraindications to itraconazole exist 1

Topical azoles can be used for mild interdigital Candida infections 4:

• Miconazole or clotrimazole cream twice daily for 2-4 weeks 4

With Nail Involvement (Candida Onychomycosis)

Itraconazole remains first-line due to shorter treatment duration and better cost-effectiveness 1:

• Itraconazole 200 mg daily for 4 weeks (fingernails) 1
• Alternative pulse therapy: Itraconazole 400 mg daily for 1 week per month 1
• Fluconazole alternatives: 50 mg daily or 300 mg weekly for 4 weeks (fingernails) 1

Important caveat: Terbinafine requires prolonged courses (48 weeks) for Candida onychomycosis with only 70-85% cure rates, making it less practical than itraconazole 1

Addressing Predisposing Factors

Elimination of predisposing factors is essential for cure and prevention of relapse 1, 4:

• For occupational exposure: Recommend protective gloves, frequent hand drying, and work practice modifications 1
• For Raynaud phenomenon: Emphasize keeping hands warm 1
• For diabetes or immunosuppression: Optimize underlying condition management 7

Special Considerations and Pitfalls

Common pitfalls to avoid 5, 3:

• Stopping treatment when skin appears healed: Patients typically discontinue therapy after 1 week when symptoms resolve, but this leads to recurrence with fungistatic agents. Emphasize completing the full course 5
• Mistaking secondary bacterial colonization for primary infection: In subcutaneous fungal infections (rare but serious), bacterial superinfection may mask the underlying fungal etiology, delaying appropriate antifungal therapy 7
• Using topical therapy alone for nail infections: Topical agents penetrate poorly through nail plates and are generally ineffective for onychomycosis 5

For deep or subcutaneous infections (e.g., sporotrichosis from rose thorn injuries): These require systemic antifungal therapy combined with possible surgical debridement and have significant morbidity 7