Tinea Pedis and Tinea Mannum

Tinea pedis is a dermatophytosis of the feet, whereas tinea manuum affects the palmar and
interdigital areas of the hand.
EPIDEMIOLOGY Present worldwide, tinea pedis and tinea manuum are the most common
dermatophytoses. Tinea pedis has risen from obscurity prior to the twentieth century to a
prevalence of approximately 10 percent today primarily as a result of modern occlusive footwear,
although increased worldwide travel has also been implicated. 32The incidence of tinea pedis is
higher among those using communal baths, showers, or pools. Whether this is caused by
increased maceration or increased transmission remains unclear. 46 Tinea manuum may be
acquired by direct contact with an infected person or animal, the soil, or autoinoculation from a
distant site. 47However, it is nearly always associated with tinea pedis 32 and has been shown to
occur most commonly following tinea pedis in the hand used to excoriate the feet. 48
Manual labor and preexisting inflammatory conditions of the hand are additional risk factors.
47Both tinea pedis and tinea manuum are exacerbated by hyperhidrosis, tropical climates, and
any anatomic abnormality leading to closed web spaces.
ETIOLOGY Tinea pedis and tinea manuum are caused predominantly by T. rubrum, T.
mentagrophytes var. interdigitale, and E. floccosum.
CLINICAL MANIFESTATIONS Tinea pedis may present as any of four forms, or a
combination thereof.
Chronic intertriginous type The most common presentation of tinea pedis, the chronic
intertriginous type, begins as scaling, erosion, and erythema of the interdigital and subdigital skin
of the feet, particularly between the lateral three toes. Under appropriate conditions, the infection
will spread to the adjacent sole or instep, rarely involving the dorsum. 32
This pattern is produced by fungal infection alone and has been termed dermatophytosis simplex.
Occlusion and bacterial coinfection soon produce the interdigital maceration, pruritus, and
malodor of dermatophytosis complex ( Fig. 205-15), or athlete's foot. 49

FIGURE 205-15 Tinea pedis, interdigital. The area is macerated and has opaque white scales and some
erosions.

Chronic hyperkeratotic type Usually bilateral with patchy or diffuse scaling limited to the thick
skin of the feet, this is also known as moccasin-type tinea pedis ( Fig. 205-16). T. rubrum, the
most common etiology, produces very few minute vesicles, leaving collarettes of scale less than
2 mm in diameter. Erythema is variable. 1 Unilateral tinea manuum commonly occurs in
association with hyperkeratotic tinea pedis, resulting in the two feetone hand syndrome ( Fig.
205-17). Oral antifungals are often required for treatment due to the high incidence of
concomitant onychomycosis and relapse. 50

FIGURE 205-16 Tinea pedis. Superficial white scales in a moccasin-type distribution. Note arciform pattern of the
scales, which is characteristic.

FIGURE 205-17 One hand, two feet presentation of T. rubrum.

Vesiculobullous type This form, typically caused by T. mentagrophytes var. interdigitale, features
tense vesicles greater than 3 mm in diameter, vesiculopustules, or bullae on the thin skin of the
sole and periplantar areas. Remissions and relapses occur with fluctuations in exposure of the
feet to heat and humidity.
Acute ulcerative type Rampant bacterial coinfection, most often from gram-negatives in
combination with T. mentagrophytes var. interdigitale, produces vesiculopustules and large areas
of purulent ulceration on the plantar surface. Cellulitis, lymphangiitis, lymphadenopathy, and
fever are frequently associated. The vesiculobullous and acute ulcerative types commonly
produce a vesicular id reaction, either as a dyshydrotic-like distribution on the hands or on the
lateral foot or toes. The vesicles are by definition KOH and culture negative. Tinea manuum
(Fig. 205-18) predominantly presents as the hyperkeratotic type, although crescentic, exfoliating,
vesicular, folliculopapular, and dorsal erythematous forms are also described. 32

FIGURE 205-18 Tinea manus. Polycyclic pattern of an eruption composed of scaling vesicles with involvement of
the thumb nail; the nail exhibits destruction of the nail plate.

LABORATORY FINDINGS KOH examination of scales reveals septate, branching hyphae.

For vesiculobullous lesions, examination of the roofs yields the highest rate of positivity. Fungal
cultures should be performed on SDA with cycloheximide and chloramphenicol.
PATHOLOGY Histologically, hyperkeratotic tinea pedis or tinea manuum is characterized by
acanthosis, hyperkeratosis, and a sparse, chronic superficial perivascular infiltrate in the dermis.
Vesiculobullous forms display spongiosis, parakeratosis, and subcorneal or spongiotic
intraepithelial vesiculation. With both types, foci of neutrophils are occasionally seen in the
stratum corneum, as well as fungal organisms with PAS or methenamine silver staining
.
DIFFERENTIAL DIAGNOSIS If KOH examination and fungal culture are negative, other
considerations for interdigital disease include psoriasis, soft corns, bacterial coinfection,
candidiasis, and erythrasma. The likelihood of candidal and bacterial infection increases with the
severity of maceration, denudation, and pruritus. 51Unlike tinea pedis, erythrasma fluoresces
coral red under a Wood lamp. The hyperkeratotic type must be differentiated from psoriasis,
hereditary or acquired keratodermas of the palms and soles, dyshydrosis, pityriasis rubra pilaris,
and Reiter's syndrome. Contact dermatitis may also be considered, although it more commonly
affects the dorsal foot than tinea pedis. Children are more likely to have peridigital dermatitis or
atopic dermatitis. Vesiculobullous or vesiculopustular presentations may be confused with
pustular psoriasis, palmoplantar pustulosis, and bacterial pyodermas.
PREVENTION AND TREATMENT Minimizing chronic moisture is important in preventing
tinea pedis. This may be achieved through talcum powder, absorbent socks, nonocclusive shoes,
and, occasionally, 20 to 25% aluminum chloride hexahydrate powder. Antifungal powders such
as undecylenic acid and tolnaftate are also beneficial. 38 Mild interdigital tinea pedis without
bacterial involvement can be treated topically with an allylamine, azole, ciclopirox, tolnaftate, or
undecenoic acid. 52Topical terbinafine for 1 week is 66 percent effective, 53 while the other
topicals generally require 4 to 6 weeks of application. The newer oral antifungals have replaced
griseofulvin as the treatments of choice for severe or refractory tinea pedis. The dosing schedule
of terbinafine is 250 mg daily for 2 weeks. Effective regimens of itraconazole for adults are 200
mg twice daily for 1 week, 200 mg daily for 3 weeks, or 100 mg daily for 4 weeks, 44 while
children should receive 5 mg/kg per day for 2 weeks. 45Fluconazole 150 mg weekly for 3 to 4

weeks or 50 mg daily for 30 days is also effective. 44 Associated onychomycosis is common; if

present, treatment of the onychomycosis is necessary to prevent recurrence of tinea pedis.
Maceration, denudation, pruritus, and malodor obligate a search for bacterial coinfection by
Gram stain and culture. Antibiotics should be started once bacterial infection is documented and
chosen based on sensitivity studies. Adjunctive topical therapy such as 0.25% acetic acid for
Pseudomonas and colorless Castellani's paint are also helpful. Finally, because vesiculobullous
tinea pedis is the result of a T cellmediated immune reaction, symptomatic relief with topical or
systemic corticosteroids may be warranted during the beginning of antifungal
treatment. 54