How to cure tinea manuum in a patient?

Treatment of Tinea Manuum

For tinea manuum without nail involvement, apply topical terbinafine 1% gel once daily for 1-2 weeks as first-line therapy, but if there is concurrent onychomycosis or extensive disease, use oral terbinafine 250 mg daily for 2-4 weeks to achieve mycological cure. 1

Topical Therapy for Localized Disease

Topical antifungals are appropriate for mild to moderate tinea manuum without nail involvement:

• Terbinafine 1% gel applied once daily for 1-2 weeks is the preferred first-line topical treatment 1
• Alternative topical options include ciclopirox 0.77% cream or gel twice daily for 4 weeks, or naftifine ointment twice daily for 4 weeks 1
• Allylamine antifungals (terbinafine, naftifine) offer shorter treatment duration (1-2 weeks) compared to azoles 2
• Continue treatment for at least one week after clinical clearing of infection 3

Oral Systemic Therapy

Oral antifungals are required for extensive disease, concurrent nail involvement, or treatment failure:

Terbinafine (Preferred Agent)

• Terbinafine 250 mg daily for 2-4 weeks achieves 86% mycological cure rate at 8 weeks for Trichophyton species 1, 4
• Particularly effective against T. rubrum and T. mentagrophytes, the most common causative organisms 2
• Obtain baseline liver function tests and complete blood count before initiating therapy 1
• If concurrent fingernail onychomycosis exists, extend treatment to 6 weeks 1
• If concurrent toenail onychomycosis exists, extend treatment to 12-16 weeks 1

Itraconazole (Alternative Agent)

• Itraconazole 100 mg daily for 15 days achieves 87% mycological cure rate 1, 5
• Effective against both Trichophyton and Microsporum species when the causative organism is unknown 1
• Monitor liver function with prolonged therapy 1
• Critical drug interactions: warfarin, certain antihistamines, antipsychotics, midazolam, digoxin, and simvastatin 1, 2
• Contraindicated in heart failure 1

Treatment Monitoring and Endpoints

Mycological cure (negative microscopy and culture), not just clinical improvement, is the definitive treatment endpoint:

• Perform repeat mycology sampling at the end of the standard treatment period 1
• Continue monthly sampling until mycological clearance is documented 1
• If clinical improvement occurs but mycology remains positive, continue current therapy for an additional 2-4 weeks 1, 6
• If no initial clinical improvement, switch to second-line therapy 1

Management of Concurrent Infections

Evaluate and treat all concurrent fungal infections simultaneously:

• Screen for concurrent onychomycosis, tinea pedis, and other dermatophyte infections 1
• Treat all sites simultaneously to prevent reinfection 1
• Extended systemic therapy is required when multiple sites are involved 1

Prevention of Recurrence

Implement comprehensive prevention strategies to avoid reinfection:

• Wear protective footwear in public bathing facilities, gyms, and hotel rooms to prevent T. rubrum reinfection 1
• Apply antifungal powders (miconazole, clotrimazole, or tolnaftate) to hands and feet 1
• Avoid skin-to-skin contact with infected individuals 2
• Do not share towels, gloves, or personal items 2
• Screen and treat family members, as over 50% of household contacts may be affected with anthropophilic species 2, 6
• Clean all fomites with disinfectant or 2% sodium hypochlorite solution 2, 6

Important Safety Considerations and Contraindications

Terbinafine:

• Contraindicated in active or chronic liver disease 2
• Contraindicated in lupus erythematosus 2
• Common side effects include gastrointestinal disturbances (49%): nausea, diarrhea, taste disturbance 2
• Serious adverse events are rare (0.04% incidence): Stevens-Johnson syndrome, toxic epidermal necrolysis 2
• Minimal drug-drug interactions compared to azoles 2

Itraconazole:

• Requires monitoring of liver function with prolonged therapy 1, 2
• Significant drug interactions require careful medication review 1, 2
• Contraindicated in heart failure 1

Common Pitfalls to Avoid

• Do not stop treatment based on clinical appearance alone - mycological cure must be documented to prevent relapse 1
• Do not use topical therapy alone for extensive disease or concurrent nail involvement - systemic therapy is required 1, 3
• Do not ignore concurrent infections at other sites - simultaneous treatment prevents reinfection 1
• Do not use terbinafine if Microsporum species are suspected - it is relatively ineffective against this organism 6