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

Treatment of Fungal Infection of the Hands

Start with topical antifungal therapy using azoles (clotrimazole, miconazole) or allylamines (terbinafine) applied once or twice daily for 2-4 weeks for dermatophyte infections (tinea manuum), but switch to oral itraconazole 200 mg daily for at least 4 weeks if you suspect Candida or if the infection is extensive or resistant to topical treatment. 1

Identify the Type of Fungal Infection First

The causative organism determines your treatment approach:

• Dermatophyte infections (tinea manuum) typically present with dry, scaly patches, often with a unilateral "one hand, two feet" pattern 2, 3
• Candida infections show moist, erythematous interdigital spaces, paronychia, or occur in patients with frequent water exposure (dishwashers, healthcare workers, food handlers) 1
• Confirm diagnosis with potassium hydroxide (KOH) preparation of skin scrapings before starting treatment when possible 4, 2

Treatment Algorithm for Dermatophyte Infections (Tinea Manuum)

First-Line: Topical Therapy

• Apply topical azoles (clotrimazole, miconazole, ketoconazole) or allylamines (terbinafine, naftifine, butenafine) once or twice daily for 2-4 weeks 1, 5
• Allylamines are preferred over azoles because they are fungicidal (kill fungi) rather than fungistatic (just stop growth), allowing shorter treatment courses of 1-2 weeks with higher cure rates 5, 3
• Continue treatment for at least one week after clinical clearing to prevent relapse 3

Second-Line: Oral Therapy

Use oral antifungals when the infection is:

• Extensive (covering large areas)
• Resistant to topical treatment after 4 weeks
• Involves the nails (onychomycosis)

• Terbinafine 250 mg daily for 2-4 weeks is the preferred oral agent for dermatophyte infections 1
• Griseofulvin 500 mg daily (or 0.5-1.0 g daily for extensive infections) is an alternative, though less commonly used now 4, 2
• For nail involvement, treatment duration extends to at least 4 months for fingernails 4

Treatment Algorithm for Candida Infections

First-Line: Oral Therapy

• Itraconazole 200 mg daily for a minimum of 4 weeks is the first-line systemic treatment for Candida hand infections 1
• Fluconazole 200-400 mg daily serves as an alternative if itraconazole is contraindicated or unavailable 1
• For Candida onychomycosis, use itraconazole 200 mg daily for 4 weeks, or pulse therapy with itraconazole 400 mg daily for 1 week per month 1

Topical Therapy Limitations

• Azole topicals can be used for mild, localized Candida intertrigo, but yeast infections respond poorly to allylamine drugs 5, 6
• Nail infections rarely respond to topical therapy alone because products penetrate poorly through the nail plate 5

Critical Adjunctive Measures

Eliminating predisposing factors is essential to cure the infection and prevent relapse:

• Recommend protective gloves for occupational water exposure 1
• Emphasize frequent hand drying, especially between fingers 1
• Address underlying conditions like diabetes or immunosuppression 6
• Investigate and treat other body sites of infection (feet are commonly involved with hand dermatophyte infections) 6, 3

Common Pitfalls to Avoid

• Do not stop treatment when skin appears healed—fungi recur more often with premature discontinuation, especially with fungistatic agents 5
• Do not use topical steroids alone—while combination antifungal/steroid agents can reduce inflammation, use them cautiously and only short-term to avoid skin atrophy 3
• Do not assume all hand infections are dermatophytes—Candida requires different treatment, and misdiagnosis leads to treatment failure 1, 7
• Do not use allylamines for suspected Candida—they are ineffective against yeast 5
• Griseofulvin is ineffective against Candida and other yeasts 4