Photo Rounds

Rash on hand

A 24-year-old man sought care for a stubborn rash that covered much of his left hand. The rash itched and after much scratching, began to crack and enlarge. The patient had applied a topical antifungal agent to his hand, and the lesion initially shrunk. But the rash flared when he stopped using the cream. The patient noted that he occasionally suffered from athlete’s foot.

What’s your diagnosis?


The patient was given a diagnosis of tinea manuum on one hand and tinea pedis on both feet. Tinea manuum is known as two feet-one hand syndrome and is caused by a dermatophyte infection. The patient was initially treating his rash appropriately with the topical antifungal, but failed to treat his concomitant tinea pedis.

The infection may be spread from the feet to the hand by scratching, as tinea pedis or onychomycosis of the toenails precede infection of the hand. The hand that is used to scratch or pick at the feet may be the hand that becomes involved (but this is not always the case).

Topical antifungals such as terbinafine, clotrimazole, or ketoconazole are first-line therapy for the feet and hand.Consider oral antifungals if the affected area is large, the patient doesn’t respond to topical therapy, or the patient is immunocompromised.

In light of the patient’s previous failure with topical therapy, he was reluctant to try this approach again. After a normal hepatic panel, his physician started him on a 2-week course of oral terbinafine 250 mg daily. Follow-up at one month showed no sign of previous infection.

Adapted from: Crandall ML. Photo Rounds: Stubborn hand rash. J Fam Pract. 2012:61:421-424.

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