Tinea Manuum: Symptoms, Types, Causes and Treatment

Tinea manuum, also known as ringworm of the hand, is a superficial fungal infection that affects the skin of the hands. Despite being less well-known than other types of tinea, such as athlete’s foot (tinea pedis) or ringworm of the body (tinea corporis), tinea manuum has significant clinical importance. Its symptoms can be mistaken for other skin conditions, leading to delayed diagnosis and treatment. In this detailed guide, we explore the symptoms, types, causes, and treatment options for tinea manuum, drawing on current evidence and real-world cases.

Symptoms of Tinea Manuum

Tinea manuum presents with a variety of symptoms that can range from mild to severe. Recognizing these signs early can help differentiate tinea manuum from other skin conditions, ensuring timely and effective treatment.

Primary	Secondary	Distinctive	Source
Scaling	Itching	Bullous	1 4 6 10
Redness	Cracking	Ulcerative	1 4 6
Dryness	Burning	Unilateral	6 4
Thickening	Pain	Symmetry	1 4 6

Table 1: Key Symptoms

Clinical Presentation

Tinea manuum typically manifests as dry, scaling patches on the palms or backs of the hands. The affected skin may become thickened, cracked, or exhibit a moccasin-like appearance. Itching and burning sensations are common, and in more severe cases, pain or even bullous (blistering) eruptions can develop, especially in zoonotic cases transmitted from animals like hedgehogs 1 4 6 10.

Unilateral vs. Bilateral Involvement

A notable feature of tinea manuum is its tendency to affect only one hand—termed “unilateral” tinea manuum—although bilateral cases do occur. The unilateral presentation is often due to the hand being used to scratch infected feet, leading to direct transfer of fungi 6. Bilateral involvement may signal more extensive or chronic infection.

Distinctive and Rare Symptoms

While most cases present with scaling, redness, and dryness, some can develop bullous or ulcerative lesions. For example, bullous tinea manuum, characterized by blisters and severe pain, has been reported in cases involving zoonotic transmission from hedgehogs 1. Ulcerative tinea manuum, though rare, can mimic other conditions like leishmaniasis and requires careful evaluation 4.

Mimics and Misdiagnosis

Because symptoms such as scaling and itching are nonspecific, tinea manuum can be mistaken for eczema, psoriasis, or contact dermatitis. However, the presence of features like central clearing, well-demarcated borders, and a history of fungal infection elsewhere (especially the feet) can help distinguish it 3 6.

Types of Tinea Manuum

Tinea manuum is not a uniform condition; its clinical and microbiological diversity reflects a range of presentations and causative organisms. Understanding the different types is critical for accurate diagnosis and management.

Clinical	Morphology	Microbial	Source
Noninflammatory	Psoriasiform	Trichophyton	3 4 6 7 8
Inflammatory	Ulcerative	Nannizzia	4 3 5
Bullous	Moccasin	Epidermophyton	1 4 6
Unilateral	Bilateral	Microsporum	6 3 4

Table 2: Clinical and Microbial Types

Clinical Variants

• Noninflammatory Type: The most common form, presenting as dry, scaling, and sometimes thickened skin. This type often resembles eczema or psoriasis, particularly when it takes on a moccasin distribution (covering the entire palm and sides of the fingers) 3 6.
• Inflammatory Type: Characterized by redness, swelling, blisters, and even ulceration. This form is less common and often associated with zoonotic transmission or specific fungal species 1 4.
• Bullous and Ulcerative Types: Bullous tinea manuum features painful blisters, while the ulcerative type (rare) presents with breaks in the skin that can be mistaken for bacterial or parasitic infections 1 4.

Laterality: Unilateral vs. Bilateral

• Unilateral Tinea Manuum: Most patients have the infection in one hand, usually the dominant hand used for scratching infected feet (tinea pedis). This is strongly supported by epidemiological evidence 6.
• Bilateral Tinea Manuum: Less common, and may be associated with severe or untreated infections, or with underlying immunocompromise 6.

Microbial Classifications

• Trichophyton Species: The most frequent cause of tinea manuum, notably T. rubrum, T. mentagrophytes, and T. erinacei (the latter being associated with hedgehogs) 1 5 7 8.
• Nannizzia gypsea: A geophilic dermatophyte responsible for rare ulcerative forms, particularly in endemic regions 4.
• Epidermophyton and Microsporum: Less commonly involved, but can cause typical or atypical presentations 6 3.

Syndromic Associations

Tinea manuum often co-exists with tinea pedis (“two feet-one hand syndrome”) and may be accompanied by fungal nail infections (tinea unguium) 6.

Causes of Tinea Manuum

Understanding the causes of tinea manuum is vital for prevention and targeted therapy. This infection results from dermatophyte fungi, but the sources and risk factors are diverse.

Pathogen	Transmission	Risk Factor	Source
Trichophyton	Animal	Scratching	1 5 6 8
Nannizzia	Soil	Foot fungus	4 6
Epidermophyton	Human	Poor hygiene	3 6 11
Microsporum	Environment	Immunosupp.	3 6 4

Table 3: Main Causes and Risk Factors

Dermatophyte Fungi

• Trichophyton Species: The principal culprits, especially Trichophyton rubrum, T. mentagrophytes, and zoonotic types like T. erinacei (hedgehog-associated) 1 5 7 8.
• Nannizzia gypsea: Acquired from soil, this fungus is less common but can cause severe, ulcerative hand infections 4.
• Epidermophyton and Microsporum: Occasionally implicated, often in particular geographic or environmental settings 3 6.

Routes of Transmission

• Autoinoculation: The majority of cases arise from self-infection, typically by scratching or touching tinea pedis lesions on the feet and subsequently transferring the fungus to the hand(s) 6.
• Animal Contact: Handling animals, especially exotic pets like hedgehogs, can introduce zoonotic dermatophytes such as T. erinacei 1 5 8.
• Soil and Environment: Less commonly, dermatophytes may be contracted from contaminated soil or surfaces, particularly for geophilic species like Nannizzia 4.

Risk Factors

• Existing Fungal Infection: Having tinea pedis increases the risk, especially if the feet are scratched frequently 6.
• Poor Hand Hygiene: Not washing hands after touching infected areas increases transmission risk 6.
• Occupational Exposure: Farmers, gardeners, and pet owners are at higher risk due to frequent contact with soil or animals 4 8.
• Immunosuppression: Chronic infections and atypical presentations are more likely in immunocompromised individuals 4 6.

Epidemiological Insights

• Studies show over 80% of tinea manuum patients also have tinea pedis, highlighting the importance of addressing both sites to prevent reinfection 6.
• Recent trends in exotic pet ownership (e.g., hedgehogs) have led to increased zoonotic cases in non-endemic regions 1 5 8.

Treatment of Tinea Manuum

Effective treatment of tinea manuum relies on accurate diagnosis, choice of appropriate antifungals, and addressing predisposing factors. With modern therapies, most patients can expect complete resolution.

Modality	Drug/Method	Duration	Source
Topical	Azoles, Allylamines	2-4 weeks	9 10 11 12
Oral	Terbinafine, Itraconazole	2-8 weeks	9 10 11
Alternative	Essential oils	2-3 weeks	12
Adjunctive	Hygiene, Treat feet	Ongoing	6 9 11

Table 4: Treatment Approaches

Topical Antifungal Therapy

• Standard of Care: For most localized cases, topical antifungals such as imidazoles (e.g., clotrimazole, ketoconazole) or allylamines (e.g., terbinafine) are effective. These are applied once or twice daily for 2-4 weeks 9 11.
• Efficacy: High cure rates are reported, especially with newer agents like topical terbinafine 10. Essential oils like Eugenia caryophyllus (clove oil) ointment have also shown promise in small studies, achieving full cure within three weeks 12.

Oral Antifungal Therapy

• Indications: Oral antifungals are recommended for:
  • Extensive or chronic infections
  • Failed topical therapy
  • Coexisting nail or scalp involvement 9 10 11
• Agents and Duration: Terbinafine (250 mg daily) or itraconazole are commonly prescribed, with treatment durations ranging from 2 to 8 weeks depending on severity. Studies show up to 86% mycological cure with 2-week oral terbinafine 10.
• Tolerance: Both drugs are generally well-tolerated, though monitoring for side effects is advised 10 11.

Adjunctive Measures

• Treat All Sites: Simultaneous treatment of tinea pedis and onychomycosis is essential to prevent reinfection (“two feet-one hand syndrome”) 6 9.
• Hygiene Education: Patients should be educated on proper hand and foot hygiene, including not scratching infected areas and regular washing 6 9 11.
• Address Zoonotic Sources: Avoid direct contact with infected animals or contaminated soil; use gloves if needed 1 4 5 8.

Special and Alternative Therapies

• Essential Oils: Topical ointments containing clove oil have shown efficacy even in cases resistant to standard antifungals, offering a cheaper alternative without adverse effects 12.
• Pulse Therapy: Intermittent dosing with oral antifungals may be considered for difficult or recurrent cases 11.

Monitoring and Follow-Up

• Assess Response: Clinical and mycological cure (negative KOH test) are used to confirm treatment success 10 12.
• Prevent Recurrence: Continued attention to hygiene and treatment of reservoir sites (like feet or nails) is critical, as relapse is common if these are overlooked 6 9 11.

Conclusion

Tinea manuum is a diverse and sometimes overlooked infection of the hands, with varied symptoms and a range of possible causes. Early recognition and comprehensive management are key to a successful outcome.

Key Takeaways:

• Tinea manuum often presents with scaling, redness, and dryness of the hands, but may also feature blisters or ulcers in rare cases 1 4 6.
• The most common cause is self-inoculation from tinea pedis, although animal and environmental sources are increasingly recognized 1 5 6 8.
• Diagnosis can be challenging due to mimicry of eczema and psoriasis; careful evaluation and mycological testing are essential 3 6.
• Effective treatment includes topical and/or oral antifungals, with adjunctive hygiene measures and simultaneous treatment of coexisting fungal infections 9 10 11.
• Alternative therapies like clove oil ointment show promise, especially in resistant cases 12.
• Patient education and follow-up are crucial to prevent recurrence and ensure complete recovery 6 9 11.

By understanding the symptoms, types, causes, and treatments of tinea manuum, patients and clinicians can work together to achieve rapid relief and prevent future infections.