Cutaneous Larva Migrans

Rhonda Lesniak, PhD, ARNP, FNP-BC

Disclosures

Dermatology Nursing. 2008;20(6):471-472. 

Content

The "Clinical Snapshot" series provides a concise examination of a clinical presentation including history, treatment, patient education, and nursing measures. Using the format here, you are invited to submit your "Clinical Snapshot" to Dermatology Nursing.

An 18-year-old male presented with complaints of a rash on both feet. He complained of intense itching and pain on his feet, stating he could barely walk. The rash evolved and spread over 1 week, with some blisters and new areas of involvement. He played volleyball with bare feet in wet dirt and sand 1 week previously. He denied any associated symptoms or aggravating factors.

Cutaneous larvae migrans, or creeping eruption, is a skin condition caused by infected larvae of dog and cat hookworms. It is commonly found in persons who are barefoot in sandy soil which has been contaminated with dog or cat feces and is most prevalent in the southeastern United States, Caribbean, Africa, Central and South America, Southeast Asia, and other subtropical and tropical climates. Those at highest risk for infestation include children, gardeners, sunbathers, plumbers, farmers, electricians, pest exterminators, and carpenters.

Cutaneous larva - right foot

One month after treatment

The most common areas of infestation are the hands, feet, buttocks, and upper thighs.

Ancylostoma braziliense and Ancylostoma caninum are the infecting agents. The ova are deposited in the feces of dogs or cats; the larvae hatch in the soil where they are viable for several weeks. While in their third developmental stage, the larvae may infect humans through penetration of skin which has come in contact with the soil. The incubation period is 1 to 6 days from initial exposure to the onset of symptoms; however, localized pruritus may begin within hours after the larval penetration. The parasites may cause a localized eosinophilic inflammation.

The classical presentation is pruritic, erythematous, raised, tunnel or serpiginous (thread-like) lesions or bullae containing serous fluid. Excoriations (from scratching) may present as secondary lesions. The lesions usually advance one or more centimeters per day and are two to three millimeters wide. The larvae are usually ahead of the advancing edge of the lesion. Diagnosis is made based on the character of the lesions and biopsy is not indicated.

Treatment includes the antihelminthic medications, such as oral albendazole, ivermectin, and topical thiabendazole. Oral thiabendazole is usually not recommended due to possible toxic adverse effects. For the control of itching, topical hydroxyzine, or OTC anti-itch creams are indicated, as well as oral antihistamines. In severe cases, cryosurgery may be used at the advancing edge of the burrow. Secondary skin infections may be treated with antibiotics.

The course of the disease is actually self-limiting as humans are "dead-end" hosts. Most of the larvae will die and the lesions will resolve within 2 to 8 weeks. The larvae are usually unable to penetrate deeper tissues. In rare cases, the larvae may migrate to visceral tissues, causing Leofflers' syndrome (persistent hypereosinophilia, hepatomegaly, and pneumonitis). If the larvae migrate through the bloodstream and to the lungs, where they produce cough and pneumonia, they may be coughed up and swallowed. Then they may attach to the lining of the small intestine, producing anemia and eosinophilic enteritis. There they mature into adult worms.

The patient should avoid sitting, lying, or walking barefoot on wet soil or sandy areas where dogs or cats may deposit feces. Gloves should be worn when working in or near wet soil or sandy areas. Patients should be encouraged to wear footwear and use a towel for lying or sitting on the ground. If the patient has a pet cat or dog, the animal should be examined by a veterinarian. The hookworm ova will be visible upon a microscopic examination of an infected animal's feces.

Encourage the patient to adhere to the treatment plan as prescribed, explaining that it may take several weeks for the lesions to resolve. Stress good handwashing to prevent the spread of the condition to others. Look for possible side effects to medications. Apply cool, moist compresses to relieve itching.

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