How should tinea manuum be treated?

Treatment of Tinea Manuum

Treat tinea manuum with oral terbinafine 250 mg daily for 2 weeks as first-line therapy, which achieves 86% mycological cure rates and is superior to topical therapy alone. 1

First-Line Oral Antifungal Therapy

Terbinafine is the preferred agent for tinea manuum due to its:

• Superior efficacy: 86% mycological cure rate at 8 weeks with just 2 weeks of treatment 1
• Shorter treatment duration: Only 1-2 weeks required compared to other agents 2, 3
• Excellent tolerability: Well-tolerated with minimal side effects 1
• Specific effectiveness against Trichophyton species: The most common causative organism 2

Dosing: Terbinafine 250 mg once daily for 1-2 weeks 2, 3

Alternative Oral Agents

If terbinafine is contraindicated or unavailable:

Itraconazole offers two effective regimens 4:

• Pulse dosing: 400 mg daily for 1 week (63% mycological cure) 4
• Standard dosing: 100 mg daily for 4 weeks (75% mycological cure) 4
• Effective against both Trichophyton and Microsporum species 5
• Important caveat: Check for drug interactions with warfarin, antihistamines, antipsychotics, midazolam, digoxin, and simvastatin 2

Fluconazole as third-line option 2:

• 50-100 mg daily for 2-3 weeks OR 150 mg once weekly for 2-3 weeks 3
• Less cost-effective than terbinafine with limited comparative data 2

When Oral Therapy is Mandatory

Oral antifungals are required for tinea manuum because 2, 6:

• Topical therapy alone is generally insufficient for hand infections
• The infection often involves hair follicles and deeper skin structures
• Resistance to topical treatment is common

Diagnostic Confirmation Before Treatment

Obtain mycological confirmation whenever possible 2, 7:

• Collect specimens via scalpel scraping from the active border of lesions 2, 7
• Perform potassium hydroxide (KOH) preparation microscopy to visualize hyphae and arthroconidia 2, 7
• Culture on Sabouraud agar if microscopy is positive 7

However, if clinical features strongly suggest tinea manuum, starting treatment empirically while awaiting confirmation is reasonable 7

Baseline Laboratory Monitoring

Check baseline liver function tests before initiating terbinafine or itraconazole, especially if pre-existing hepatic abnormalities are suspected 2

Treatment Endpoint and Follow-Up

Mycological cure, not just clinical improvement, is the definitive treatment endpoint 2, 7:

• Continue treatment for at least 1 week after clinical clearing to prevent relapse 7, 8
• Repeat mycology sampling until clearance is documented 2
• If clinical improvement occurs but mycology remains positive, continue therapy for an additional 2-4 weeks 7

Prevention of Recurrence

Address predisposing factors 7:

• Screen and treat family members, especially for anthropophilic species like T. tonsurans (>50% of family members may be affected) 2
• Clean contaminated items: Disinfect or use 2% sodium hypochlorite solution on towels, combs, and personal items 5, 2
• Avoid sharing personal items and skin-to-skin contact with infected individuals 2, 7
• Completely dry hands after washing 7

Common Pitfalls to Avoid

• Never rely on topical therapy alone for tinea manuum—it cannot eradicate the infection 5, 6
• Avoid combination antifungal-corticosteroid products as part of antifungal stewardship to prevent resistance 6
• Do not use griseofulvin as first-line: It requires longer treatment duration and has lower cure rates than terbinafine 2
• Do not stop treatment at clinical clearing: Continue until mycological cure is achieved 2, 7