Introduction

Tinea Manuum (TM) is a fungal infection that results in inflammation of the hands, which can lead to a rash on the palms or between the finger digits that may look red and inflamed.¹ It can be a sudden onset (acute) or occur over a long period of time (chronic). A common name for Tinea Manuum is ‘ringworm.’ It can be spread by coming into contact with infected sites, materials, animals or soil.

Chronic infections can be cumbersome, painful and impact the lifestyle of those affected. Managing chronic conditions requires constant monitoring, treatment and re-evaluation of treatments to ensure that the most effective and efficient option is prescribed. 

• Chronic Tinea Manuum (CTM) presents in a more scaly, dry patch that is thicker, less inflamed and less red. It develops over a longer period of time and can cause discomfort. It’s caused by persistent infection by dermatophytes such as Trichophyton rubrum
• Long-term management challenges include the development of resistant infections
• Incorrect self-diagnosis and subsequent treatment with antibacterials instead of antifungals can lead to other problems
• The impact of chronic medication on other organs, such as the liver, i.e., liver toxicity
• The development of contact dermatitis or vulnerabilities to other skin infections

Epidemiology and aetiology

CTM has a global prevalence of 0.3-13% which is highly impacted by geographical location.^2,3 Prevalence and demographic factors:

Causative agents are dermatophytes of the Trichophyton species, specifically Trichophyton rubrum:

1. Trichophyton mentagrophytes
2. Epidermophyton floccosum
3. Trichophyton verrucosum
4. Trichophyton interdigitale
5. Microsporum canis

Risk factors contributing to chronicity

• Gender (males are more predisposed to CTM
• Blood pressure complications (hypertension)
• Immune suppression
• Atherosclerosis
• Diabetes

Clinical presentation

• Scaly and inflamed skin usually presents between the fingers

Differential diagnosis

Considering other skin infections as part of the differential diagnosis is important in the correct treatment and management strategies. These include:

• Viral
• Bacterial
• Other zoonotic pathogens
• Psoriasis
• Eczema

Diagnostic tools and techniques

Proper diagnosis can be done by using several different techniques, such as:

• PCR techniques: These are usually used in larger diagnosis cases and research purposes, as they can determine the microorganism at the genetic and subspecies level
• Direct microscopy: These include obtaining nail clippings if the fungal infection has spread to the nails. By staining the nail clippings with KOH, using microscopy, doctors can determine if the infection is caused by a fungal agent by looking for the presence of hyphae
• A fluorescent staining technique that stains the chitin present in fungi and aids in the identification and diagnosis of fungal infection
• Histopathology: This is a tissue staining technique where lesions can be observed at the tissue level for differential diagnosis
• Dermoscopy: This is a unique test where a scraping of the skin is taken and examined for Tinea Manuum diagnosis⁴

Challenges in management

Misdiagnosis and delayed diagnosis

• Symptom similarity with other skin infections can confuse diagnosis and further complicate treatment 
• Delays in seeking treatment can also cause complications as instead of only treating one infection, a secondary infection, i.e., bacteria, may need to be treated as well. Often, those presenting with Tinea Manuum will not seek treatment months or years after symptomatic presentation
• Differential diagnosis is important, as treating primary infections incorrectly may lead to CTM
• Differential diagnosis is also dependent on resource availability. The correct tools and techniques are vital for correct diagnosis, as this ultimately impacts treatment and management strategies
• Resistance to antifungals has also become a recent concern 
• Prolonged treatment is also a problem, as this can often be a financial burden or impact the patient's ability to work
• Poor patient adherence to medication
• Lifestyle choices can also impact whether the infection resolves. This includes occupational hazards, environmental conditions, i.e., frequent exposure to infected soils
• Health conditions - a poor diet and immune system can impact infection resolution

Treatment strategies

• Topical or oral antifungals, or corticosteroids when necessary
• Combination treatment strategies, such as antifungal and keratolytics. 
• Preventative measures for fungal infections on both the hands and feet can be effective in minimising the chance of recurrence or spread of the fungal infection from one site to another 
• Disinfection to eliminate fomites that may be contributing to persistent cases
• Emerging therapies and novel antifungal agents
• Advances in diagnostic technology
• Multidisciplinary approaches to management

Conclusion

Chronic Tinea Manuum is an uncomfortable skin infection that can be treated if diagnosed and managed correctly. Furthermore, one of the biggest contributing factors to CTM appears to be caused by delayed diagnosis and misdiagnosis, emphasising the importance of correct tools and techniques used to accurately determine the treatment regimen required to resolve infection. The development of resistant species and related skin conditions due to delayed treatment highlights the importance of research into skin conditions such as CTM. Due to the scarcity of reports available of Tinea manuum, more effort needs to be invested into understanding genetic susceptibility, environmental impact and occupational conditions and their impact on health. 

FAQs

Can tinea manuum be treated with an antibacterial and steroid cream?

No. If caused by a fungal microorganism, Tinea manuum needs to be treated with an antifungal cream. The use of steroids is complicated, and it is better to obtain a prescription from a doctor rather than self-treatment, as this can exacerbate the infection

Can other microorganisms cause tinea manuum?

Yes, other microorganisms such as bacteria, viruses, fungi and zoonotic microorganisms can cause skin infections. 

Is chronic tinea manuum different from acute infections?

Yes, they are. Acute infections are usually associated with inflamed and red skin that can often be painful. Chronic tinea manuum presents differently and can often be observed to be scaly and not inflamed in the infected area.