Pictorial case study

Dr Jean Watkins, a sessional GP in Hampshire

This patient had peeling skin on one hand only

The case
For 20 years this 59-year-old man had been aware of peeling of his right hand. Apart from a slight soreness and itch, and the nuisance of flaking skin, it did not trouble him unduly.

Assuming it to be dermatitis he avoided contact with detergents by wearing cotton-lined rubber gloves and tried a variety of creams and ointments. When he noticed changes in his nails and a rash on the backs of his hands and on his feet he finally sought help from his GP, who took skin scrapings and nail clippings from the hand.

What is the diagnosis, differential diagnoses and management?

Diagnosis and management
A diagnosis of tinea was confirmed and the man was treated with a course of oral terbinafine. Much to the patient's relief, the condition cleared.

Some cases of tinea of the hand, as in this man, present with only one hand affected. The patient complains of a slowly progressive peeling, a powdery filling of the hand creases, dryness and slight itching of the palm.

This type of tinea is usually caused by Trichophyton rubrum or mentagrophytes or Epidermophyton floccosum. Skin scraping of the affected area for microscopy and culture will identify the fungus. Further clues to the diagnosis are athelete's foot and/or fungal nails, which are often associated with the problem.

Tinea manuum may also present with a rash that might be recognised as tinea corporis.

Management involves the use of antifungal agents. Topical preparations such as an imidazole or terbinafine may be sufficient for localised problems, if used twice daily for two to four weeks, and including a good margin of normal skin. For more extensive or persistent cases, or where nails are involved, an oral antifungal is necessary. Terbinafine is also the drug of choice if there is nail involvement, daily for three to six months.

Possible different diagnoses

  • Dermatitis of the hand.
  • Psoriasis.
  • Keratolysis exfoliativa.
  • Keratoderma.

Differential diagnosis

Hand dermatitis:

  • May be of genetic origin, caused by irritant substances or an allergic phenomenon.
  • Usually bilateral and may affect both palms and backs of the hands.
  • Dryness, followed by inflammation, papules, pustules, scaling, fissures and exudation.
  • In long-standing cases, nails may be affected with pitting, thickening and transverse ridging.

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