History

Fact Explanation
Diffuse scaling of palmer surface of one hand. Tinea manuum is a superficial dermatophyte infection involving the hand. Usually caused by the fungi Trichophyton rubrum. [1],[2],[3],[4],[5], [6],[7]
Erythematous scaly ring like papules in dorsal surface on hand. This presentation is more common when a zoophilic or geophilic causative organisms are responsible. Due to acute inflammation in advancing margin, erythema most pronounced at the periphery. The lesions expand slowly and healing leaves a typical ring like pattern. [7]
Scaly hyperkeratosis of the soles and heels with white, macerated areas in toe webs. When the palms are infected, the feet may also commonly infected. A typical pattern of involvement of one hand and both feet. [1],[6],[7]
Pruritis Most of the patients complain of pruritus. May range from mild to intense itching and is dependent on the causative organisms.[1],[2],[3], [6]
Contact history There may be a history of contact with another site of infection, such as tinea pedis, contact with another infected person, direct contact with an infected animal or soil or history of sharing contaminated object such as a towel or gardening tool. [1],[2],[3],[6]
History of immunosupression. Protection against fungal infection is caused by cell mediated immunity. HIV infection, long term steroid therapy, Cushings' syndrome, malnutrition and diabetes are possible risk factors in the history. [1],[2],[3],[5],[6]
References
  1. MARKS JR, JAMES G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4th ed. Elesvier. 2006,125-128.
  2. WELLER Richard, HUNTER PJB, John AA, SAVIN John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  3. MARKS, Ronald ed. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  4. KUMAR, Parveen and CLARK, Michael ed. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  5. QADIM, H.H. GOLFOROUSHAN, F. AZIMI, H. and GOLDUST, M. Factors leading to dermatophytosis. Annals of parasitology. [online] 2013;59(2):99-102. [Viewed on 28.04.2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24171304
  6. Tinea manuum, DermNet NZ . 29 Dec 2013. [Viewed on 29.04.2014] Available from: http://dermnetnz.org/fungal/tinea-manuum.html
  7. Tinea manuum (hands), pedis (feet), and unguium (nails). The Primary Care Dermatology Society. 12th April 2014. [Viewed on 28.04.2014] Available from: http://www.pcds.org.uk/clinical-guidance/tinea-pedis-feet-manuum-hands-and-unguium-nails

Examination

Fact Explanation
Diffuse scaling of palmer surface of one hand with powderly scales more prominent in the creases. Tinea manuum is a superficial dermatophyte infection which involves the stratum corneum. Fungal keratinase disrupts the keratin structure facilitating diffuse scaling. [1],[2],[3],[4],[5],[6]
Single or numerous circular ring like erythematous, well marginated scaly plaques on the skin over the dorsal aspect of the affected hand. Dermatophyte lesions appear because of delayed or type-4 hypersensitivity reaction as a response to metabolic products of causative organisms. [1],[2],[3],[7]
Blistering rash on the edges of the fingers or palm. The blisters appear in crops and contain a sticky clear fluid. Their may be a peeling edge. Border of the wrist side is clearly demarcated. This is useful when considering other differential diagnosis. [1],[5]
Coexisting Tinea pedis. Commonly associated with Tinea pedis. Therefore Tinea manuum is called as "one hand & two feet syndrome". Patient's feet must be examine for signs of Tinea pedis and Tinea unguium. [1],[2],[3],[5]
References
  1. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  2. WELLER Richard, HUNTER PJB, SAVIN John AA, JOHN A and DAHL Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  3. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  4. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.
  5. Tinea manuum, DermNet NZ . 29 Dec 2013. [Viewed on 29.04.2014] Available from: http://dermnetnz.org/fungal/tinea-manuum.html
  6. Tinea manuum (hands), pedis (feet), and unguium (nails). The Primary Care Dermatology Society. 12th April 2014. [Viewed on 28.04.2014] Available from: http://www.pcds.org.uk/clinical-guidance/tinea-pedis-feet-manuum-hands-and-unguium-nails
  7. QADIM, H.H. GOLFOROUSHAN, F. AZIMI, H. and Goldust, M. Factors leading to dermatophytosis. Annals of parasitology. 2013;59(2):99-102. [Viewed on 28.04.2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24171304

Differential Diagnoses

Fact Explanation
Irritant contact dermatitis Their is weeping, crusting, scaling and blistering of palm with pruritus. However the absence of demarcating margin is important to differentiate. Usually involve both palms. [1],[2],[3]
Allergic contact dermatitis Has a positive history of exposure to occupational and domestic exposure to allergens. Usually involves both palms. [1],[2],[3]
Palmer psoriasis Their are sharply demarcated scaly plaques. These plaques are bilateral and more elevated and erythematous. Usually their are psoriatic plaques in the other sites of the body. [1],[2],[3],[4]
Granuloma annulare The lesions of the common type of granuloma annulare often lie over the knuckles and are composed of dermal nodules fused in to rough ring shape. On the hand the lesions are skin colored or slightly pink. [1],[2],[3]
Xerosis Xerosis or dry skin may cause bilateral diffuse scaling palmer surface. The border of the lesion is not well demarcated. [1],[2],[3]
Dyshidrotic eczema Dyshidrotic eczema is a condition in which small blisters develop on the hands and feet. Blisters are often itchy. Usually involves both palms and Their is not a well demarcation. [1],[2],[3]
References
  1. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  2. WELLER, Richard, HUNTER PJB, SAVIN John AA, JOHN A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  3. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  4. KUMAR, Parveen and CLARK, Michael. KUMAR & CLARK'S Clinical Medicine. 8th Ed. ELSEVIER. 2012,1200-1201.

Investigations - for Diagnosis

Fact Explanation
Woods light examination Uses ultraviolet light to observe skin closely. It reveals epidermophytes with green fluorescence. Yet some causative fungus does not fluoresce. [1],[2],[3]
Light microscopic examination The skin scrapings should be taken with a small curette or a scalpel blade. The specimens are cleared in potassium hydroxide. Branching hyphae and spores can easily be seen through light microscope. [1],[2],[3],[4]
Culture Culture should be carried out in a mycology or bacteriology laboratory. Transport medium is not necessary, and specimens can be sent in folded black paper or a dry petri dish. The report may take as long as a month: microscopy is much quicker. [1],[2],[3],[4]
References
  1. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  2. WELLER, Richard, HUNTER PJB, SAVIN John AA , John A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  3. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  4. Tinea manuum, DermNet NZ . 29 Dec 2013. [Viewed on 29.04.2014] Available from: http://dermnetnz.org/fungal/tinea-manuum.html

Investigations - Followup

Fact Explanation
Periodic monitoring Periodic monitoring is important in patients on systemic antifungal therapy to identify possible side effects such as hepatotoxicity and neutropenia. [1],[2],[3]
Follow up visit Important to see the response to treatments and identify complications such as secondary bacterial infection. [1],[2],[3]
References
  1. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  2. WELLER Richard, HUNTER PJB, SAVIN John AA, JOHN A and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  3. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.

Management - General Measures

Fact Explanation
Educate the patient Tinea manuum is a superficial fungal infection which can be treated successfully. [1],[2],[3]
Advise regarding hygiene Tinea manuum is a contagious and communicable fungal infection. Therefore advise to avoid contact with infected patients and not to share clothes, towels, bedlinen, etc. Advise to wear gloves when handling animals and soil. [1],[2],[3]
References
  1. MARKS JR, James G. and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  2. WELLER Richard, PJB. HUNTER, SAVIN John AA, JOHN A. and DAHL, Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  3. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.

Management - Specific Treatments

Fact Explanation
Local imidazole preparations An imidazole containing preparation (such as miconazole, econazole and clotrimazole) used twise daily for 3-4 week period is usually adequate. Imidazoles interfere with fungal oxidative enzymes to cause lethal accumulation of hydrogen peroxide. Reduces the formation of ergosterol, an important constituent of fungal cell wall which thus becomes permeable to intracellular constituents. [1],[2],[3],[4],[5]
Terbinafin cream Acts by inhibiting fungal squalaneepoxidase and does not interact with cytochrome p-450 system. It is fungicidal. Terbinafine 1% cream given to apply daily to the infected area untill the skin is clinically clear and then to apply for 1-2 weeks to prevent recurrence. [1],[2],[3],[4]
Systemic antifungals When topical treatment has failed systemic drugs should be considered. Must consider possible drug interactions and possible side effects when considering systemic therapy. [1],[2],[3],[4],[5]
References
  1. MARKS JR, JAMES G and MILLER Jeffery. Lookilgbill & Marks’ Principles of Dermatology. 4thEd. Elesvier. 2006,125-128.
  2. WELLER Richard, HUNTER PJB, SAVIN John AA, JOHN A and DAHL Mark V. Clinical Dermatology. 4th Ed. Blackwell publishing. 2008, 248-252.
  3. MARKS, Ronald. ROXBURGH'S Common Skin Diseases. 17th Ed. Arnold Publishers. 2003, 39-43.
  4. BENNET P.N. and BROWN, MJ. CLINICAL PHARMACOLOGY. 9th Ed. CHURCHILL LIVINGSTONE. 2003, 263-267.
  5. KATZUNG, Bertram G. MASTERS, Susan B. and TREVOR, Anthony J. Basic and Clinical Pharmacology. 12th Ed. Tata McGraw-Hill. 2012, 849-860.