Fitzpatricks dermatology in general madicine – 8th editions

TINEA PEDIS AND TINEA MANUUM

Tinea pedis denotes dermatophytosis of the feet, whereas tinea manuum involves the palmar
and interdigital areas of the hands.
Infection of the dorsal aspects of feet and hands is considered to be tinea corporis.
EPIDEMIOLOGY.
Occurring worldwide, tinea pedis and tinea manuum are the most common dermatophytoses.
High prevalence, estimated to be around 10%, is attributed primarily to modern occlusive
footwear, although increased worldwide travel has also been implicated. Incidence of tinea
pedis is higher among those using communal baths, showers or pools. With the ubiquitous
presence of dermatophytes in the environment, however, it may be that host factors such as
an individual’s immune response to dermatophytes, in addition to exposure, play a
determining role in the acquisition of tinea pedis. The authors, however, are not aware of any
studies formally addressing this question.
Tinea manuum is acquired through direct contact with an infected person or animal, the soil,
or via autoinoculation. Most commonly only one hand (singular: tinea manus) is involved,
concomitant with infection of feet and toenails for which the term “two feet–one hand”
syndrome has been coined. This classic presentation of tinea manus represents a secondary
infection of the hand acquired from excoriating and picking infected feet and toenails.48
Tinea manuum should be suspected in individuals who have fine dry scaling of the palm or
palms, often accentuated in the creases.
ETIOLOGY.
Tinea pedis and tinea manuum are caused predominantly by T. rubrum (most common), T.
interdigitale, and E. floccosum.
CLINICAL FINDINGS.
Tinea pedis may present as any of four forms, or combinations thereof.
Interdigital Type.
The most common presentation of tinea pedis begins as scaling, erythema and maceration of
the interdigital and subdigital skin of the feet, and in particular between the lateral third and
fourth and fourth and fifth toes (Fig. 188-12A). Under appropriate conditions, the infection
will spread to the adjacent sole or instep, but it rarely involves the dorsum. Occlusion and
bacterial coinfection (Pseudomonas, Proteus, and Staphylococcus aureus) soon produce the
interdigital erosions with pruritus and malodor that are characteristic of the dermatophytosis
complex, or “athlete’s foot.”

Figure 188-12 Tinea pedis. A. Interdigital type. The inderdigital space is macerated with
opaque white scales and has erosions. B. Moccasin type. Patchy erythema and scaling in a
moccasin distribution on the foot. The arciform pattern of scales is characteristic. C. Bullous
type. Ruptured bullae, erosions and erythema on the plantar aspect of the great toe. Hyphae
were detected on KOH 10% preparation obtained from epithelial cell on the roof of the inner
aspect of the bulla.
 Fitzpatricks dermatology in general madicine – 8th editions

Chronic Hyperkeratotic (Moccasin) Type.

In chronic hyperkeratotic type tinea pedis, there is patchy or diffuse scaling on the soles and
the lateral and medial aspects of the feet, in a distribution similar to a moccasin on a foot
(Fig. 188-12B). The degree of erythema is variable, and there may also exist few minute
vesicles that heal with collarets of scale less than 2 mm in diameter. The most common
pathogen is T. rubrum followed by E. floccosum and anthropophilic strains of T. interdigitale.
Vesiculobullous Type.
Vesiculobullous type of tinea pedis, typically caused by zoophilic strains of T. interdigitale
(former T. mentagrophytes var. mentagrophytes), features tense vesicles larger than 3 mm in
diameter, vesiculopustules, or bullae on the soles and periplantar areas (Fig. 188-12C). This
type of tinea pedis is uncommon in childhood but has been caused by T. rubrum.49
Acute Ulcerative Type.
Tinea pedis with zoophilic T. interdigitale along with rampant bacterial superinfection with
Gram-negative organisms produces vesicles, pustules and purulent ulcers on the plantar
surface. Cellulitis, lymphangitis, lymphadenopathy and fever are frequently associated.
Vesiculobullous and acute ulcerative types commonly produce a vesicular Id reaction, either
on the lateral foot or toes, or on the lateral aspects of the fingers.
Tinea manus, dermatophyte infection of the hand, usually has a noninflammatory
presentation with diffuse dry scaling and accentuation in the creases (Fig. 188-13). However,
vesicles, pustules and exfoliation may be present, especially when zoophilic dermatophytes
involved. Tinea manus commonly occurs in association with moccasin type tinea pedis and
onychomycosis, which should also be treated to minimize relapse.

Figure 188-13 Tinea pedis and

manus. “Two feet–one hand”
presentation of Trichophyton rubrum.
Scaling in the involved
(right) hand is accentuated in the
creases.

LABORATORY TESTS.
KOH examination of blister roofs
(vesicules or bullae) yields the
highest rate of positive findings.

DIFFERENTIAL DIAGNOSIS OF TINEA PEDIS

Most Likely
Interdigital: erosio interdigitalis blastomycetica, erythrasma, bacterial coinfection
Hyperkeratotic: dyshidrosis, psoriasis, contact dermatitis, atopic dermatitis, hereditary or
acquired keratodermas Vesiculobullous: dyshidrosis, contact dermatitis, pustular psoriasis,
bacterid, palmoplantar pustulosis, bacterial pyodermas, scabies
Consider
Pityriasis rubra pilaris
Rule Out
Reactive arthritis