Photo Rounds

Rash on left hand, feet

A 32-year-old man presented to his family physician (FP) with an itchy rash on his left hand that he’d had for 3 months. He stated that he was right-handed and didn’t know why it was only on one hand. When asked if he had a rash on his feet, he stated that some of his toenails had been “messed up” for years. His work required him to do manual labor, but he was otherwise in good health.

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The FP diagnosed this patient with two foot one hand syndrome , which is a fungal infection involving both feet and one hand. To be sure of the diagnosis, the FP performed a potassium hydroxide (KOH) preparation from the scale on the left hand and found typical branching hyphae caused by a dermatophyte. (See video on how to perform a KOH preparation.) The dermatophyte was most likely Trichophyton rubrum , but it wasn’t necessary to determine the exact species in order to treat this condition.

Two foot one hand syndrome is not rare, but it is somewhat puzzling as to why it involves only one hand while involving both feet. Also, it does not preferentially involve the dominant hand. In this case, the patient’s 2 large toenails had visible onychomycosis and 3 of the nails on his left hand had fungal changes (his dominant right hand was not affected). Tinea pedis was seen between the toes in a moccasin distribution, as well.

Treatment for this condition usually requires an oral antifungal agent. (If, however, the nails were not involved and there were contraindications to an oral antifungal, then a topical antifungal cream could be tried first.)

The patient described here had no history of liver disease or alcohol abuse. So the FP prescribed terbinafine 250 mg daily for one month to fully clear the skin infection and a follow-up appointment was set for 4 weeks. At that appointment, the FP planned to discuss continuing oral treatment for 2 additional months to clear the fungal infection from the nails. If ongoing oral terbinafine was needed, liver function tests could be performed at that time.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Fungal overview. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine . 2nd ed. New York, NY: McGraw-Hill;2013:771-776.

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