summary Cutaneous Fungal Infections of the hand are usually mild and are broken into 4 types: cutaneous, subcutaneous, deep and systemic. Diagnosis is made by careful history and physical exam and confirmed with positive fungi cultures. Treatment is generally oral antifungal antibiotics with deep infections requiring surgical debridement. Epidemiology Incidence Most common subcutaneous infection of the hand is sporotrichosis Demographics onychomycosis is more common in middle-aged women Risk factors more common to have fungal infection in macerated skin areas (skin folds) Candida more prevalent in patients working in moist environments or under water. immunocompromised patients at risk for Deep infections Etiology Pathophysiology Depends on fungus species Candida species are responsible for chronic or recurrent paronychia and found in moist environments Sporothrix schenckii that is found in plants and soil. Classification Infections divided into three categories cutaneous includes nail bed infections (onychomycosis) subcutaneous includes sporothrix schenckii from rose thorn prick deep orthopaedic manifestation tenosynovial septic arthritis osteomyelitis organisms include endemic coccidiomycosis histoplasmosis blastomycosis opportunistic include candidiasis mucormycosis cryptococcocis asperfillosisi requires surgical debridement Onychomycosis Introduction defined as fungal infection in vicinity of nail bed (cutaneous) most common organisms are trichophyton rubrum a destructive nail plate infection candida chronic infection of nail fold Treatment topic antifungal treatment & nail plate removal indications first line of treatment systemic griseofulvin or ketoconazole indications recalcitrant cases Sporothrix schenckii Introduction Sporothrix schenckii a common soil organism a subcutaneous infection rose thorn in classic mechanism of subcutaneous transmission Presentation physical exam will show local ulceration (papule) at site of penetration with time additional lesions form in region on lymphatic vessels may show proximal lymph node involvement Evaluation S schenckii isolated at room temperature on Sabouraud dextrose agar Treatment oral itraconazole for 3 to 6 months indications mainstay of treatment has replaced potassium iodide due to side effects which included thyroid dysfunction rash GI symptoms Coccidiomycosis Introduction found in southwest arid regions (e.g., new mexico) often a deep infection Presentation manifestations include subclinical pulmonary involvement orthopaedic manifestations synovitis arthritis periarticular osteomyelitis Treatment amphotericin B & surgical debridement Histoplasmosis Introduction histoplasma capsulatum infection found in Mississippi River Valleys and Ohio Presentation usually subclinical often found incidentally on CXR may present with tenosynovial infection Evaluation diagnosed by skin testing Treatment amphotericin B & surgical debridement / tenosynovectomy Prognosis usually resolve spontaneously may have serious infection in immunocompromised host