You are in: eMedicine Specialties > Dermatology > PARASITIC INFECTIONS Cutaneous Larva MigransArticle Last Updated: Apr 10, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Lydia A Juzych, MD, Consulting Staff, Department of Dermatology, Henry Ford Health Sciences Center Lydia A Juzych is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Medical Student Association/Foundation, American Medical Women's Association, Michigan State Medical Society, and Phi Beta Kappa Coauthor(s): Margaret C Douglass, MD, Program Director, Department of Dermatology, Henry Ford Hospital Editors: Daniel Mark Siegel, MD, MS, Director, Procedural Dermatology Fellowship Program, Clinical Professor of Dermatology, Department of Dermatology, State University of New York Downstate; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic; Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System Author and Editor Disclosure Synonyms and related keywords: creeping eruption, ground itch, dew itch, CLM, plumber's itch, sandworm disease, Ancylostoma braziliense, A braziliense, parasite infection INTRODUCTIONSection 2 of 10
  BackgroundCutaneous larva migrans (CLM) is the most common tropically acquired dermatosis whose earliest description dates back more than 100 years. It manifests as an erythematous, serpiginous, pruritic, cutaneous eruption caused by accidental percutaneous penetration and subsequent migration of larvae of various nematode parasites. It is most commonly found in tropical and subtropical geographic areas and the southwestern United States; however, the ease and the increasing incidence of foreign travel by the world's population have no longer confined CLM to these areas. PathophysiologyThe life cycle of the parasites begins when eggs are passed from animal feces into warm, moist, sandy soil, where the larvae hatch. They initially feed on soil bacteria and molt twice before the infective third stage. By using their proteases, larvae penetrate through follicles, fissures, or intact skin of the new host. After penetrating the stratum corneum, the larvae shed their natural cuticle. Usually, they begin migration within a few days. In their natural animal hosts, the larvae are able to penetrate into the dermis and are transported via the lymphatic and venous systems to the lungs. They break through into the alveoli and migrate to the trachea, where they are swallowed. In the intestine they mature sexually, and the cycle begins again as their eggs are excreted. Humans are accidental hosts, and the larvae are believed to lack the collagenase enzymes required to penetrate the basement membrane to invade the dermis. Therefore, the disease remains limited to the skin when humans are infected. FrequencyUnited StatesCLM is rated second to pinworm among helminth infections in developed countries. Mortality/MorbidityThe condition is benign and self-limited but can cause a disturbing pruritus. RaceNo specific racial predilection exists because CLM depends on exposure. SexCLM demonstrates no specific sexual predilection because CLM depends on exposure. AgeCLM can affect persons of all ages because it depends on exposure, but it tends to be seen in children more commonly than in adults. CLINICALSection 3 of 10
History
Physical
Causes
DIFFERENTIALSSection 4 of 10
Impetigo Tinea Pedis
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| Drug Name | Thiabendazole (Mintezol) |
|---|---|
| Description | DOC. Inhibits helminth-specific fumarate reductase, which inhibits microtubule formation, leading to impaired glucose uptake and inhibition of malate dehydrogenase. Third-generation heterocyclic anthelmintic. |
| Adult Dose | Apply topical 10-15% susp (sometimes compounded with corticosteroid cream) under occlusive dressing qid for at least 1 wk Alternatively, 25-50 mg/kg/d PO divided q12h for 2-5 d Some drug references, such as PDR, suggest 10 mg/lb body weight bid for 2-4 d; treat for 7-10 d in hyperinfection syndrome; not to exceed 3 g/d |
| Pediatric Dose | 25-50 mg/kg/d PO divided q12h; not to exceed 3 g/d; some drug references, such as PDR, suggest a dosage of 10 mg/lb body weight bid for 2-4 d |
| Contraindications | Documented hypersensitivity; impaired kidney or liver function |
| Interactions | May elevate serum levels of theophylline increasing toxicity; monitor serum levels and reduce dose prn |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Anorexia, nausea, vomiting, diarrhea, hematuria, headache, and dizziness may occur; closely monitor in hepatic or renal dysfunction; prior to initiating therapy, supportive therapy is necessary for patients who are anemic, dehydrated, or malnourished; use in confirmed worm infestation (not prophylactically) |
| Drug Name | Ivermectin (Stromectol) |
|---|---|
| Description | Semisynthetic macrocyclic lactone antiparasitic agent with broad-spectrum action against nematodes by producing flaccid paralysis through binding of glutamate-gated chloride ion channels. May become DOC because of safety, low toxicity, and single dosing, which enhance patient compliance. |
| Adult Dose | 12 mg or 200 mcg/kg PO once |
| Pediatric Dose | <5 years: 150 mcg/kg PO once >5 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | May interact with other ligand-gated chloride channels, such as those gated by GABA |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Although rare, may cause fever, glandular tenderness, pruritus, muscle aches, and headaches; treat mothers who intend to breastfeed only when risk of delayed treatment outweighs possible risks to the newborn caused by ivermectin excretion in milk; repeat courses of therapy may be required in patients who are immunocompromised; may cause nausea, vomiting, and mild CNS depression; may cause drowsiness |
| Drug Name | Albendazole (Albenza) |
|---|---|
| Description | Broad-spectrum benzimidazole carbamate anthelmintic that acts by interfering with glucose uptake and disrupting microtubule aggregation. Use as alternative to thiabendazole. |
| Adult Dose | 400 mg PO qd for 3 d or 200 mg PO bid for 5 d with meals |
| Pediatric Dose | <2 years: 200 mg/d for 3 d and repeat in 3 wk, if necessary >2 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | Coadministration with carbamazepine may decrease efficacy; dexamethasone and praziquantel may increase toxicity |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Constipation, abdominal pain, diarrhea, nausea, dizziness and reversible alopecia may occur; discontinue use if LFTs increase significantly (resume when levels decrease to pretest values) |
| Drug Name | Mebendazole (Vermox) |
|---|---|
| Description | Broad-spectrum anthelmintic that inhibits microtubule assembly and irreversibly blocks glucose uptake, thereby depleting the parasites' glycogen stores. Has shown some efficacy in treating CLM. |
| Adult Dose | 200 mg PO bid for 4 d |
| Pediatric Dose | <2 years: Not established >2 years: Administer as in adults |
| Contraindications | Documented hypersensitivity |
| Interactions | Carbamazepine and phenytoin may decrease effects; cimetidine may increase levels; may increase effects of insulin and oral hypoglycemics |
| Pregnancy | C - Safety for use during pregnancy has not been established. |
| Precautions | Abdominal pain, diarrhea, fever, pruritus, and skin rash may occur; adjust dose in hepatic impairment |
| Media file 1: Patients who were sunbathing nude on a beach in Martinique presented with classic, erythematous, serpiginous tracts on the left heel. | |
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| Media file 2: Cutaneous larva migrans on the right thumb. | |
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| Media file 3: Cutaneous larva migrans on the left thigh. | |
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Cutaneous Larva Migrans excerpt
Article Last Updated: Apr 10, 2006
