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TINEA MANUUM

Introduction

Tinea manuum, often referred to as “ringworm,” is a contagious fungal infection caused by a dermatophyte. It often occurs in the feet and secondarily in a hand (“one hand/ two feet”), where it may affect the dorsum, palm, and/or interdigital folds of one or both hands. Tinea manuum typically presents as a diffuse white scaling/hyperkeratosis (keratoderma), and possibly erythematous patches and/or pustules. In many cases tinea manuum is mistaken for other skin conditions of the hands, which makes diagnostic vigilance crucial.1-3
 

Pathophysiology

  • Tinea manuum is primarily caused by an infection of the dermatophytic fungus Trichophyton rubrum, which can spread from person to person, animals to humans, or soil to humans.4
  • Rare cases have also been reported in which the infection was caused by Hendersonula toruloidea and Scytalidium hyalinum.3

Related Anatomy

  • Dermis
  • Epidermis
  • Keratin
  • Interdigital folds

Incidence and Related Conditions

  • The estimated lifetime risk of acquiring a dermatophyte infection at any site is 10-20%.5
  • The incidence of tinea manuum varies drastically from one country to the next, with international epidemiological rates ranging from 4.4-16.4%.3
  • Tinea manuum primarily occurs in adults, and is only seen rarely in children.3
  • Tinea manuum is less common than tinea pedis.5
  • Onychomycosis 
  • Tinea barbae
  • Tinea capitis
  • Tinea corporis
  • Tinea incognito
  • Tinea pedis
  • Tinea versicolor

Differential Diagnosis

  • Eczema 
  • Irritant contact dermatitis
  • Keratoderma
  • Keratolysis exfoliativa 
  • Pompholyx
  • Psoriasis 
  • Xerosis
ICD-10 Codes

  • SKIN - COMMON HAND RASHES: TINEA MANUUM

    Diagnostic Guide Name

    SKIN - COMMON HAND RASHES: TINEA MANUUM

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    TINEA MANUUMB35.2   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Tinea manuum Dermatophytosis)
  • Dermatophytosis on dorsal right hand (arrow)
    Dermatophytosis on dorsal right hand (arrow)
Symptoms
Red raised ring-like lesion
Dry, peeling, or scaly skin, most prominent at the edge of the lesion
Blisters
Skin discoloration
Pruritus (usually mild)
Skin thickening
Typical History

A typical patient is a 44-year-old man who regularly plays in a recreational rugby league. After a recent practice, he realized that he had forgotten his flip-flops and consequently had to take a shower barefoot. A few days later, the man noticed an itchy, ring-like rash on his right foot and began to scratch it soon thereafter for relief. Several days later, a similar rash appeared on the palm of his right hand, which he had used to scratch his foot. This rash was also associated with some mild itching, and the skin surrounding it eventually started to appear dry, scaly, and hard. The emergence of these latest symptoms led the man to seek out treatment from a dermatologist.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Conservative

Conservative5,6

  • Topical antifungal therapy
    • Usually the first line of treatment for most tinea manuum infections
    • Terbinafineor a topical azole for 2-64-6 weeks
    • Systemic antifungal therapy
      • May be needed for severe or extensive infections, or if topical antifungals fail to elicit significant improvements.
      • Terbinafine
      • Griseofulvin
Operative
  • Surgery is not indicated for tinea manuum.
Complications

COMPLICATIONS3 

  • Flexor tendon disuse contractures 
  • Lymphangitis 
Outcomes
  • Patients typically experience complete resolution with adherence to a topical antifungal regimen.
Key Educational Points
  • Distinguishing tinea manuum from similar inflammatory dermatoses is often challenging, and diagnostic delays, errors, and unnecessary therapies may occur as a result.1
  • On examination, look for asymmetrical distribution—usually of the palm of a single hand—a ring-like rash with an elevated border, and dry, peeling, or scaling skin.2,6
  • When tinea manuum and tinea pedis occur concomitantly, tinea pedis usually develops first and is transmitted to the hand from the feet by scratching. Accordingly, all patients with tinea manuum should undergo foot examination, with treatment of the feet in order to eliminate a possible reservoir of infection3
  • Patients should be advised to wash or replace potentially contaminated clothing or other products that may have touched the skin after successful treatment to prevent further spread of the infecting dermatophyte.6
  • Combination topical steroid/antifungal creams should be avoided, as treatment of any fungal infection with topical steroid may result in initial symptomatic improvement, followed by rapid acceleration/expansion of dermatophytosis and symptoms
  • Utilizing a Wood's Lamp and dermatoscopy can be useful in during a work up.
References

New and Cited Articles

  1. Errichetti E, Stinco G. Dermoscopy in tinea manuum. An Bras Dermatol 2018;93(3):447-448. PMID: 29924225
  2. Marks JG, Miller JJ. Lookingbill and Marks’ Principles of Dermatology. Fifth Ed. London, New York: Saunders Elsevier; 2013.
  3. Veraldi S, Schianchi R, Benzecry V, Gorani A. Tinea manuum: A report of 18 cases observed in the metropolitan area of Milan and review of the literature. Mycoses. 2019. [Epub] PMID: 30929271
  4. Rhee DY, Kim MS, Chang SE, et al. A case of tinea manuum caused by Trichophyton mentagrophytes var. erinacei: the first isolation in Korea. Mycoses 2009;52(3):287-290. PMID: 18643919
  5. Noble SL, Forbes RC, Stamm PL. Diagnosis and management of common tinea infections. Am Fam Physician 1998;58(1):163-174, 177-168.PMID: 9672436
  6. Moriarty B, Hay R, Morris-Jones R. The diagnosis and management of tinea. BMJ 2012;345:e4380.PMID: 22782730
  7. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin.12thEd. Philadelphia, PA. Elsevier, 2016.
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