Introduction

What is tinea manuum?

Tinea manuum is a skin fungus that usually hits the hands, mainly the palms and the gaps between the fingers.¹

Causes and risk factors 

Fungal infection of the hands can occur by direct contact with an infected individual, animal, or indirectly with soil and items that have become contaminated.. Tinea manuum stands out among skin fungus issues because it shows clear signs like skin redness and peeling. Proper discrimination from other cutaneous lesions, such as eczema or dermatitis, should be done to help determine a precise diagnosis and thereby receive effective therapy.¹

Topical antifungal treatments

Over-the-counter (OTC) antifungal creams

Clotrimazole

 Clotrimazole, a man-made medicine, is mainly put on the skin to stop fungus on the skin and in the vagina from yeasts and fungus bugs. Tests in labs show it works best on types like Candida, Trichophyton, and Microsporum,  Malassezia furfur (Pityrosporon orbiculare). It also shows some in vitro activity against selected Gram-positive bacteria, and at extremely high levels of concentration, exhibits activity against Trichomonas spp.²

Terbinafine

Terbinafine, the latest member of the family, was a product of studies conducted to maximise the antifungal profile of efficacy of the allylamines through chemical structure manipulation: addition of a triple bond and alkylation of the alkyl side chain near it. Terbinafine introduces an innovation in antifungal treatment in the sense that it possesses a unique mechanism of action; it has fungicidal properties, is effective when administered orally as well as topically, and demonstrates a superior safety and efficacy profile compared to the other existing antifungal treatments.³

Prescription topical antifungals

Ciclopirox

Ciclopirox olamine (CPO) is a hydroxypyridone derivative with structural and mechanism-of-action differences compared to the other recognised antifungal drugs.¹ It has been a topical antifungal drug used for more than three decades and was approved in June 2004 by the US-FDA. Most existing literature is concerned with its nail lacquer formulation to treat onychomycosis; its topical cream formulations are still massively underused. The primary emphasis of this article will be on the cream formulation.⁴

Application guidelines and duration

Expected treatment duration

Treatment duration of tinea manuum may differ depending on the severity of the infection:

Topical Treatment: Topical antifungals in general would be applied for as much as six weeks. Two weeks as a bare minimum for initial response is recommended by some guidelines, with a maximum period of up to four weeks, if needed.

Oral Treatment: If oral therapy is needed, treatment usually takes between 2 and 6 weeks, depending on the drug and patient-specific factors.⁵

Oral antifungal medications

Commonly used oral antifungals

• Terbinafine
• Itraconazole
• Fluconazole

Because oral agents offer superior skin penetration compared to most topical preparations, oral therapy might be more effective in the management of hyperkeratotic tinea pedis. Itraconazole, terbinafine and griseofulvin are appropriate for oral treatment. Itraconazole and terbinafine are very slightly more effective than griseofulvin. Fluconazole once-weekly dosing is another choice, particularly in non-compliant patients.⁶

Adjunctive and supportive therapies

Home remedies and hygiene practices

• Keeping hands dry and clean
• Avoiding sharing personal items
• Using antifungal powders

Prevention strategies

• Proper handwashing techniques
• Wearing gloves in high-risk environments

Patients should be taught to wear loose-fitting cotton or synthetic clothing that wicks moisture away from the surface. Socks with these kinds of properties are also recommended. Regions that would likely become infected are to be dried thoroughly before clothing is applied. Patients are also taught to avoid going barefoot and also sharing clothes.⁵

Several of the old agents lacking particular antimicrobial activity are still utilised, such as Whitfield's ointment and Castellani's (Carbol fuchsin solution) paint. The effectiveness of these preparations has not been adequately quantified. Lesions involving extensive body surface area that do not clear with repeated treatment with various topical agents should be considered for systemic therapy. There is no specific comparative study on the combination of systemic and topical vs. monotherapy with systemic antifungal treatment.

Topical drugs possess superior pharmacokinetics compared to their systemic counterparts. Therefore, the combination should be superior to systemic and topical alone regarding mycological clearance. The combination should be from various groups in order to cover extensively and also to avoid the emergence of resistance. Medication administered for a shorter duration with a higher dose has less possibility of drug resistance compared to a lower dose for a longer duration. A drug having keratophilic and lipophilic nature, administered in higher concentration, will produce a reservoir effect and will cause improved mycological clearance.⁵

Management of tinea manuum

• Many skin and pill-based fungus cures can be used to treat hand fungus. When we can, we use skin cures first because they have fewer whole-body side effects and don't mix badly with other drugs
• Tests show there is no big change in how well different fungus-fighting drugs work. This includes allylamines (like terbinafine and naftifine), imidazoles (like clotrimazole, fluconazole, itraconazole, and ketoconazole), and other kinds like butenafine and ciclopirox olamine
• Regimens take 4 to 6 weeks, except newer preparations such as luliconazole and econazole (ecoza, spectazole), which typically take approximately 2 to 4 weeks of therapy
• Further, the anti-inflammatory properties (eg, bifonazole) and antibacterial activity (eg, clotrimazole (gram-positive and gram-negative cocci) and isoconazole (gram-positive bacteria, including MRSA)) of various topical antifungals confer certain value when selecting the drug. Although nystatin treats candida effectively, it cannot be used against dermatophytes; hence, tinea manuum cannot be treated using this
• Systemic antifungals for tinea manuum are indicated in cases where there is a co-infection of the nails, involvement of multiple body areas (like the "two-foot, one-hand syndrome"), immunosuppression, recurrent infections, or when topical treatments have failed. The oral medications used are terbinafine and itraconazole, which have similar cure rates
• Corticosteroid use is controversial but may be useful in highly inflamed cases to alleviate pruritus or burning and, in selected patients, to ensure compliance with treatment. When corticosteroids are used, the corticosteroid therapy should be given concurrently with antifungal therapy, but only for the first week of antifungal therapy⁷

When to see a doctor?

• Signs of worsening infection
• Failure to respond to treatment
• Risk of spreading to other body parts

Primary care providers typically diagnose and initiate treatment; however, certain cases can be complex and may necessitate a referral to a dermatologist or infectious disease specialist, particularly in chronic or recurrent situations or for patients suspected of having an underlying skin condition like tinea manuum.⁷

Conclusion

Often, tinea manuum is associated with tinea pedis; in other cases, limited types are seen to involve the hands alone. The worldwide prevalence of tinea manuum stresses the importance of a thorough evaluation by clinicians. Proper diagnosis is dependent on careful history-taking and detailed physical examination, at times requiring additional laboratory studies. Misdiagnosis may cause undue patient discomfort for extended periods, highlighting the importance of early recognition and treatment initiation to decrease morbidity and re-establish manual function.

This task looks at the risks, testing troubles, and top ways to treat tinea manuum. It shows the key job of the main care doctors in handling most cases. It also points out how key it is to send patients to skin doctors when the test results are not clear or when normal treatments don't work well. Interprofessional collaboration is essential to the attainment of optimal patient outcomes, especially in recurrent or refractory diseases, where interprofessional collaboration can increase the accuracy of diagnosis and the effectiveness of therapy.

Early treatment and diagnosis are crucial in reducing morbidity and enabling manual function. Most cases of tinea manuum can be treated by primary care physicians; however, if there is a doubtful diagnosis or a poor response to treatment, the patient should be referred to a dermatologist. Referral is also wise if immunodeficiency is suspected or diagnosed as a causative factor in the occurrence of tinea manuum.⁷

Tinea manum typically shows scaling and is often accompanied by itching. Dermatophytes are the main culprits behind tinea manum. For severe or complicated cases, a combination of topical and oral antifungal treatments is advised. Tinea manum caused by dermatophytes generally has a more favourable outlook compared to cases caused by nondermatophytes.¹