What is the treatment for a fungal rash on the hands?

Treatment of Fungal Rash on the Hands

For fungal rashes on the hands, topical azole antifungals (clotrimazole 1% or miconazole 2% cream applied twice daily for 2-4 weeks) are first-line therapy for dermatophyte infections, while Candida infections require either topical azoles or oral fluconazole depending on severity. 1

Determining the Type of Fungal Infection

The treatment approach differs significantly based on whether the infection is caused by dermatophytes (ringworm/tinea) versus Candida species:

• Dermatophyte infections (tinea manuum) typically present as dry, scaly patches with raised borders, often unilateral 2
• Candida infections more commonly occur in moist areas between fingers, with maceration, and are often associated with chronic hand wetness or paronychia 3

First-Line Treatment for Dermatophyte Hand Infections

Topical therapy is preferred for localized infections:

• Clotrimazole 1% cream applied twice daily for 2-4 weeks 1
• Miconazole 2% cream applied twice daily for 2-4 weeks 1
• Terbinafine 1% cream applied once or twice daily for 1-2 weeks is highly effective, achieving mycological cure in >80% of patients 4, 5

Key advantage: Terbinafine is fungicidal (kills fungi) rather than fungistatic (stops growth), allowing shorter treatment duration and lower recurrence rates 5

Oral Therapy for Extensive or Resistant Cases

When topical therapy fails or infection is extensive:

• Oral fluconazole 150-200 mg weekly for 2-4 weeks for dermatophyte infections 1
• Oral terbinafine 250 mg daily for 1-2 weeks for tinea corporis/cruris (similar efficacy for hand infections) 2
• Oral itraconazole 100-200 mg daily for 2 weeks as an alternative 2

Treatment for Candida Hand Infections

For Candida infections of the hands (often with paronychia):

• Topical azoles (clotrimazole, miconazole, or ketoconazole) are effective first-line agents 3, 6
• Nystatin topical applied 2-3 times daily until healing is complete 7
• Oral itraconazole 200 mg daily or pulse therapy (400 mg daily for 1 week per month) is first-line for Candida onychomycosis or extensive infection, requiring minimum 4 weeks for fingernails 3
• Oral fluconazole 50 mg daily or 300 mg weekly is an effective alternative if itraconazole is contraindicated 3

Critical point: Terbinafine has limited activity against Candida species and requires much longer treatment (48 weeks showed only 70-85% cure rates), making azoles strongly preferred 3, 8

Addressing Predisposing Factors

Essential for preventing recurrence:

• Eliminate chronic hand wetness and occupational exposures 3
• For paronychia, drainage is the most important intervention 3
• Apply moisturizer after hand washing to maintain skin barrier 3
• Avoid irritants including hot water, harsh soaps, and prolonged glove occlusion without underlying moisturizer 3
• Keep infected areas dry, particularly important for intertrigo-type infections 3

When to Switch Therapy

• If no improvement after 2 weeks of appropriate topical therapy, switch to a different class of antifungal agent or consider oral therapy 1
• Consider fungal culture if infection is recalcitrant to identify non-dermatophyte moulds, which may require different treatment 3

Common Pitfalls to Avoid

• Do not use terbinafine for suspected Candida infections - it has poor activity against Candida albicans and requires prolonged treatment even for C. parapsilosis 3, 8, 4
• Avoid stopping treatment when skin appears healed - fungistatic agents (azoles) require the full treatment course to prevent recurrence, as they depend on epidermal turnover to shed living fungi 5
• Do not rely on topical therapy alone for nail involvement - nail infections require systemic treatment as topical agents penetrate poorly through the nail plate 5