A 58-year-old man requests evaluation for dermatitis that has been affecting his right hand for more than 1 year. He works in maintenance and frequently is in contact with detergents. Examination reveals hyperkeratosis and scaling of the right palm; the left palm is clear. Examination elsewhere is unremarkable, except for diffuse scaling and erythema of both feet, accompanied by nail dystrophy.
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Unilateral fungal infections of the hand may present as a dry, scaly hyperkeratotic palm occurring in the presence of chronic moccasin-type scaly rash. The dermatophyte Trichophyton rubrum is the usual cause, and toenails and fingernails may also be affected.1
Two-feet-one-hand syndrome is also called bilateral plantar tinea pedis with coexistent unilateral tinea manuum. If nail involvement is clinically apparent, treatment with an oral antifungal agent should be considered because topical therapy alone is usually not effective. Oral agents may eliminate the reservoir in the toenails and prevent recurrent two-feet-one-hand dermatophyte infections in 50% to 60% of cases.2
Patients who have underlying conditions such as peripheral vascular disease, diabetes, or immunodeficiency are more susceptible to onychomycosis. A patient’s age, family history, occupation, and lifestyle may play a role in the recurrence of onychomycosis. A poor response to topical and/or oral therapy is demonstrated by the presence of very thick nails, extensive involvement of the entire nail unit, lateral nail disease, and yellow spikes.2
A retrospective multicenter study of patients with two-feet-one-hand syndrome over 15 years revealed that tinea pedis and onychomycosis generally preceded the development of tinea manuum.3 It was noted that tinea manuum usually developed in the hand used to scratch the feet or touch the toenails. The study also showed that the disease was more likely to develop at an earlier age in those whose occupations involved high-intensity use of the hands. A case-control analysis and laboratory study conducted in 2 dermatology hospitals in China also reported a significant relationship between tinea manuum and the hand reportedly used to scratch the feet.4
It is important to make the correct diagnosis and distinguish unilateral tinea manuum from the bilateral id reaction of the palms associated with inflammatory tinea pedis. Id reaction is a vesicular eruption, resembling pompholyx, whereas chronic T. rubrum infection of the hand is xerotic and scaly. Contact dermatitis can also manifest as tense vesicles and bullae appearing on one hand, but fungal culture and potassium hydroxide examination will be negative.
Aroob Moin, DPM, is a podiatry-dermatology fellow at St. Luke’s Medical Center in Bethlehem, Pennsylvania.
Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College and an adjunct assistant professor of dermatology at the University of Pennsylvania Medical College. He practices dermatology in Hazleton, Pennsylvania.
1. Kick G, Korting HC. The definition of Trichophyton rubrumsyndrome. Mycoses. 2001;44(5):167-171.
2. Scher RK, Baran R. Onychomycosis in clinical practice: factors contributing to recurrence. Br J Dermatol. 2003;149(Suppl 65):5-9.
3. Daniel CR 3rd, Gupta AK, Daniel MP, Daniel CM. Two-feet-one-hand syndrome: a retrospective multicenter survey. Int J Dermatol. 1997;36(9):658-660.
4. Zhan P, Ge YP, Lu XL, She XD, Li ZH, Liu WD. A case-control analysis and laboratory study of the two-feet-one-hand syndrome in 2 dermatology hospitals in China. Clin Exp Dermatol. 2010;35(5):468-472.