What is the recommended treatment for Tinea manuum?

Treatment of Tinea Manuum

For tinea manuum, oral terbinafine 250 mg once daily for 2 weeks is the recommended first-line treatment, achieving 86% mycological cure rates with excellent tolerability. 1

Oral Antifungal Therapy (First-Line)

Tinea manuum requires systemic treatment due to the hyperkeratotic nature of palmar skin, which limits topical penetration. 1

Terbinafine (Preferred)

• Dosing: 250 mg once daily for 2 weeks 1
• Efficacy: Achieves 86% mycological cure at 8 weeks post-treatment, with 71% effective therapy rates (mycological cure plus clinical resolution) 1
• Advantages: Fungicidal activity allows shorter treatment duration compared to azoles 1
• Tolerability: Well-tolerated with fewer side effects than placebo in clinical trials 1

Itraconazole (Alternative)

• Dosing: 100 mg daily for 15 days or 200 mg daily for 7 days 2
• Efficacy: 87% mycological cure rate for dermatophyte infections 2
• Considerations: Broader spectrum than terbinafine, covering Candida and nondermatophyte moulds 3
• Drug interactions: Enhanced toxicity with warfarin, certain antihistamines (terfenadine, astemizole), antipsychotics, midazolam, digoxin, cisapride, and simvastatin; decreased efficacy with H2 blockers, phenytoin, and rifampicin 3

Diagnostic Confirmation

Always confirm diagnosis before initiating treatment through potassium hydroxide preparation or culture. 4, 5

• Collect specimens via scalpel scraping from the leading edge of lesions 4
• Microscopy provides rapid confirmation, while culture identifies the specific organism 5
• Accurate diagnosis prevents unnecessary treatment and identifies resistant organisms 4

Treatment Failure Management

If no clinical improvement occurs after completing initial therapy: 3

1. Assess compliance with medication regimen 3
2. Evaluate drug absorption and potential interactions 3
3. Consider organism sensitivity through culture and sensitivity testing 3
4. Screen for reinfection sources including tinea pedis (very common association) 1

If clinical improvement occurs but mycology remains positive:

• Continue current therapy for an additional 2-4 weeks 3

If no clinical improvement:

• Switch to alternative agent (itraconazole if terbinafine was used initially) 3

Critical Concurrent Management

Treat Associated Tinea Pedis

• Tinea manuum frequently coexists with tinea pedis ("one hand, two feet" pattern) 1
• Topical terbinafine 1% cream once daily for 1 week is highly effective for concurrent foot infections 6, 7
• Failure to treat pedal infection leads to reinfection of hands 1

Family and Contact Screening

• Screen all household members for dermatophyte infections, particularly with anthropophilic species like T. tonsurans 4
• Over 50% of family members may harbor infection, often asymptomatically 3, 4
• Treat all positive cases to prevent reinfection 3

Environmental Decontamination

• Clean all fomites (towels, gloves, tools) with disinfectant or 2% sodium hypochlorite solution 4
• Use separate towels for hands and other body parts 8
• Ensure complete drying of hands after washing 8

Monitoring and Treatment Endpoint

Mycological cure, not just clinical resolution, is the definitive treatment endpoint. 4

• Repeat mycology sampling until clearance is documented 3, 4
• Clinical improvement may precede mycological cure by several weeks 3
• Premature discontinuation based on clinical appearance alone risks relapse 4

Common Pitfalls to Avoid

• Using topical therapy alone: Inadequate penetration through hyperkeratotic palmar skin leads to treatment failure 1
• Ignoring concurrent tinea pedis: The most common source of reinfection 1
• Stopping treatment at clinical clearance: Residual fungal elements cause relapse 3, 4
• Failing to screen contacts: Household transmission perpetuates infection cycles 3, 4