Tinea Manum Conclusion

8/9/2019 Tinea Manum Conclusion

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Psoriasis of the palms and hyperkeratotic eczema are often confused. Differentiation is sometimes

somewhat arbitrary. Often, hyperkeratotic plaques are localized at points of contact, `for example

with tools, but not all frictional hyperkeratosis is necessarily an expression of psoriasis. The

possibility of psoriasis koebnerizin into areas of contact dermatitis should not be forotten

!lleric and irritant contact dermatitis and constitutional eczema of the hands may only be

distinuishable by a careful history and patch testin. They commonly coexist. "uperimposed

irritant contact dermatitis from home and work exposures is common.

This is an unusual form of cutaneous candidiasis that manifests as a diffuse eruption beinnin as

indi#idual #esicles and spreadin into confluent areas in#ol#in the trunk, thorax, and extremities.

The associated eneralized pruritus is increased in se#erity in the enitocrural folds, anal reion,

axillae, and hands and feet.

Topical therapy includes witfield oinment, azole $miconazole and clotrimazole%, imidazole

$ ketoconazole%, or allylamines $ terbinafine or naltifine cream%, these are applied twice daily for &

weeks.

Pathogenesis Dermatophytes are not endoenous pathoens. Transmission of dermatophytes to

humans occurs #ia three sources, each resultin in typical features $Table '(.(%. )hile


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! special mention should be made of rinworm beinnin under

rins, wrist watches, and where anatomical deformities or occupational

usae predispose to maceration between the fi ners.

3ere, there may be a particular susceptibility to T. mentagrophytes

#ar. interdigitale infections, and in such cases infection may occur

without ob#ious foot in#ol#ement 56. Poor peripheral circulation

and palmar keratoderma are other possible predisposin factors

5*6.

Clinical features. T. rubrum infection may take se#eral different

clinical forms. 3yperkeratosis of the palms and fi ners affectin

the skin diffusely is the most common #ariety, and is unilateral in

about half of cases. The accentuation of the fl exural creases is a

characteristic feature. Other clinical #ariants include crescentic

exfoliatin scales, circumscribed #esicular patches, discrete red

papular and follicular scaly patches, and erythematous scaly

sheets on the dorsal surface of the hand. The latter forms are more

likely to be zoophilic infections.

Differential diagnosis. Dermatophyte infections of the palmare often quiet and chronic, commonly passin unnoticed or

misdianosed. 7ontact dermatitis, especially the primary irritant

#ariety, psoriasis, pityriasis rubra pilaris, constitutional eczemas,

keratoderma, syphilis and poststreptococcal peelin must all be

considered. -n rin infections and web space cases with anatoSuperfi

cial mycoses 36.33

mical deformity, candidosis and bacterial intertrio should be

excluded.

8nilateral scalin should always alert the clinician to the necessity

of takin scrapins. 9ail chanes may help0 pittin suests

psoriasis, but subunual hyperkeratosis if present should always

be scraped. -f the palmar infection spreads to the dorsal surface,more classical annular lesions may be seen, althouh this happens

relati#ely infrequently. Tinea manuum, like tinea cruris and tinea

faciei, is sometimes modifi ed by inappropriate treatment with

topical steroids leadin to further dianostic diffi culties.

Control. The pre#alence of tinea manuum is directly related to

the le#el of tinea pedis in the population. Prompt treatment of

tinea pedis and the use of separate towels are sensible measures

that can be recommended, but it is likely that tinea manuum will

continue to occur sporadically and a reater awareness of this

condition, so that it may be reconized promptly, is of prime

importance.

+ild interdiital tinea pedis without bacterial in#ol#ement

is treated topically with allylamine, imidazole,

ciclopirox, benzylamine, tolnaftate, or undecenoic

acid based creams.'& Terbinafine cream applied twice

daily for week is effecti#e in ((: of cases.'; The dosin

schedule of oral terbinafine is *;< m daily for

* weeks. -traconazole in adults is i#en &


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durin the initial period of antifunal treatment of

#esiculobullous tinea pedis. +aceration, denudation,

pruritus, and malodor obliate a search for bacterial

coinfection by ?ram stain and culture, the results of

which most often demonstrate the presence of ?ramneati#e

oranisms includin Pseudomonas and Proteus.

Patients suspected of ha#in ?ramneati#e coinfections

should be treated with a topical or systemic

antibacterial aent based on the culture and sensiti#ity

report. !ssociated onychomycosis is common1 if present,

more durable treatment of the onychomycosis is

necessary to pre#ent recurrence of tinea pedis. 9ewer

oral antifunal aents ha#e replaced riseoful#in as

the treatments of choice for se#ere or refractory tinea

pedis when this infection is also accompanied by onychomycosis.

-traconazole $2i. *>*% is a hihly lipophilic compound

that has a wide spectrum of acti#ity.&& -n #itro,

it is funistatic and effecti#e aainst dermatophytes,yeast, molds, and dimorphic funi.&;4&'

+@73!9 -"+ O2 !7T-O9 . -traconazole inhibits

& demethylase, a microsomal cytochrome

P&;< enzyme, in the funal membrane $2i. *>**%.&A

& Demethylase is necessary for the con#ersion of

lanosterol to erosterol, which is the principal structural

component of the funal cell membrane.&( 7onsequently,

the accumulation of & methylsterols leads

to the impairment of membrane permeability and

membranebound enzyme acti#ity and to the arrest of

funal cell rowth.

9D -7!T -O9 ". -traconazole has the broadest efficacy

compared to other commonly prescribed antifunals.

&' Thus, it is a firstline therapy for infections

due to Candida and other nondermatophyte species

$Box *>*>%.

Pediatric. -traconazole can be used to treat tinea

capitis in children. -t is more often prescribed in the

capsule formulation with food or acidic be#eraes

such as colas because the cyclodextrin in the liquid

form of itraconazole causes more astrointestinal side

effects such as diarrhea and also due to reports of neoplasms

associated with hih doses in murine and ratmodels.;& 9e#ertheless, for children who cannot swallow

capsules or take capsules with food, the solution

has a pleasant taste and is considered to be safe.;; -traconazole

is dosed at ; m=k per day for &4( weeks.;(

7hildren who weih between ; and >< k require

one


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for treatment of pediatric onychomycosis. 2or better

compliance due to decreased ad#erse effects, lower

cost, and o#erall reduced exposure to dru, one can

prescribe a pulsed reimen of ; m=k=day for week

alternatin with > weeks off1 two pulses are recommended

for finernail in#ol#ement and three pulses

for toenail in#ol#ement.C

The oral solution is a ood option for oropharyneal or

esophaeal candidiasis in children, e#en in fluconazoleresistant

infections.;>

!dult. -traconazole has been appro#ed for the treatment

of onychomycosis caused by dermatophytes;&

and is effecti#e as continuous or pulse therapy. !

*month course of itraconazole pulse therapy is necessary

for finernail onychomycosis, while toenail onychomycosis

requires a >month course. ! sinle course

consists of **1 Box *>*'% has been used since

C;A for the treatment of dermatophyte infections.;C

?riseoful#in is not effecti#e for candidiasis, deep funal

infections, or pityriasis #ersicolor.

+@73!9-"+ O2 !7T-O9

?riseoful#in is funistatic in #itro,;C and has a narrow

spectrum of antimycotic acti#ity. -t disrupts microtubulemitotic spindle formation, thereby causin mitotic

arrest at the metaphase stae.**%.> "qualene epoxidase, a

complex, microsomal noncytochrome P&;< enzyme,

catalyzes the first enzymatic step of erosterol synthesis0

the con#ersion of squalene into squalene epoxide.

7onsequently, terbinafine causes an abnormal intracellular

accumulation of squalene and a deficiency in

erosterol.& -n#itro accumulation of squalene accountsfor the drus funicidal acti#ity by weakenin the cell

membrane, while deficiency of erosterol is associated

with the drus funistatic acti#ity, as erosterol is a

component of funal membranes required for normal

rowth.&

Because of its hih selecti#ity, terbinafine is enerally

well tolerated with a low incidence of ad#erse side

effects. The most common side effects after oral administration

are of a astrointestinal nature $>.;:4;.


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loss of taste, fatiue, and malaise.*A4>> ! few cases

of hepatocellular in/ury $includin fulminant hepatic

failure%,>&,>; re#ersible aranulocytosis,>( and se#ere

skin reactions, includin toxic epidermal necrolysis

and erythema multiforme, were also reported.>'

Eisks and Precautions

Terbinafine should be prescribed with caution in

patients with hepatic disease or history of hepatic

toxicity with other medications $Box *>**%. 2urthermore,

there is insufficient data to recommend its use

in patients with renal impairment. Because terbinafine

rarely causes a lupuslike rash and neutropenia,

patients with known systemic lupus erythematosus or

immunodeficiency also may not be ood candidates

for this medication.

Tinea Manum Conclusion

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