Cutaneous Larva Migrans
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Cutaneous larva migrans (CLM) is the most common tropically acquired dermatosis whose earliest description dates back more than 100 years. Cutaneous larva migrans manifests as an erythematous, serpiginous, pruritic, cutaneous eruption caused by accidental percutaneous penetration and subsequent migration of larvae of various nematode parasites. Cutaneous larva migrans is most commonly found in tropical and subtropical geographic areas and the southwestern United States. It has become an endemic in the Caribbean, Central America, South America, Southeast Asia, and Africa. However, the ease and the increasing incidence of foreign travel by the world’s population have no longer confined cutaneous larva migrans to these areas. [1, 2, 3, 4, 5, 6, 7]
Also see the Medscape Drugs & Diseases article Pediatric Cutaneous Larva Migrans.
In cutaneous larva migrans (CLM), the 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 of cutaneous larva migrans 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 lack the collagenase needed to penetrate the basement membrane and invade the dermis. Therefore, cutaneous larva migrans remains limited to the skin when humans are infected.
The pruritic symptoms occur secondary to an immune response to both the larvae and their products. [8]
Common etiologies and where the parasites of cutaneous larva migrans (CLM) are most commonly found include the following:
Ancylostoma braziliense (hookworm of wild and domestic dogs and cats) is the most common cause. [9] It can be found in the central and southern United States, Central America, South America, and the Caribbean. [10]
Ancylostoma caninum (dog hookworm) is found in Australia.
Uncinaria stenocephala (dog hookworm) is found in Europe.
Bunostomum phlebotomum (cattle hookworm)
Rare etiologies include the following:
Ancylostoma ceylonicum
Ancylostoma tubaeforme (cat hookworm)
Necator americanus (human hookworm)
Strongyloides papillosus (parasite of sheep, goats, and cattle)
Strongyloides westeri (parasite of horses)
Ancylostoma duodenale
Pelodera (Rhabditis) strongyloides [11]
Gnathostorna spinigerum
Strongyloides stercoralis
Bunostornum phlebotomum
Strongyloides myopotami
Strongyloides procyonis [8]
Cutaneous larva migrans is rated second to pinworm among helminth infections in developed countries. Prevalence is high in regions of warm climate, where individuals may be more inclined to walk barefoot (eg, beaches, lower socioeconomic communities) and come in contact with animal feces. [12, 13]
No specific racial predilection exists because cutaneous larva migrans depends on exposure.
Cutaneous larva migrans demonstrates no specific sexual predilection because cutaneous larva migrans depends on exposure.
Cutaneous larva migrans can affect persons of all ages because it depends on exposure, but it tends to be seen in children more commonly than in adults.
The prognosis for cutaneous larva migrans is excellent. Cutaneous larva migrans is a self-limiting disease. Humans are accidental, dead-end hosts, with the larva dying and the lesions resolving within 4-8 weeks, as long as 1 year in rare cases.
Persons who travel to tropical regions and pet owners should be aware of this condition. For patient education resources, see the patient education article Foreign Travel.
Edelglass JW, Douglass MC, Stiefler R, Tessler M. Cutaneous larva migrans in northern climates. A souvenir of your dream vacation. J Am Acad Dermatol. 1982 Sep. 7(3):353-8. [Medline].
Herbener D, Borak J. Cutaneous larva migrans in northern climates. Am J Emerg Med. 1988 Sep. 6(5):462-4. [Medline].
Jones WB 2nd. Cutaneous larva migrans. South Med J. 1993 Nov. 86(11):1311-3. [Medline].
Patel S, Sethi A. Imported tropical diseases. Dermatol Ther. 2009 Nov-Dec. 22(6):538-49. [Medline].
Tamminga N, Bierman WF, de Vries PJ. Cutaneous larva migrans acquired in Brittany, France. Emerg Infect Dis. 2009 Nov. 15(11):1856-8. [Medline].
González F CG, Galilea O NM, Pizarro C K. [Autochthonous cutaneous larva migrans in Chile. A case report]. Rev Chil Pediatr. 2015 Oct 8. [Medline].
Vega-Lopez F, Hay RJ. Parasitic worms and Protozoa. Burns T, Breathnach S, Cox N, Griffiths C, eds. Rook’s Textbook of Dermatology. 8th ed. United Kingdom: Wiley-Blackwell Publisher (P) Ltd; 2010. 37.16–37.17.
Veraldi S, Persico MC, Francia C, Schianchi R. Chronic hookworm-related cutaneous larva migrans. Int J Infect Dis. 2013 Apr. 17 (4):e277-9. [Medline].
Bowman DD, Montgomery SP, Zajac AM, Eberhard ML, Kazacos KR. Hookworms of dogs and cats as agents of cutaneous larva migrans. Trends Parasitol. 2010 Apr. 26(4):162-7. [Medline].
Schuster A, Lesshafft H, Talhari S, Guedes de Oliveira S, Ignatius R, Feldmeier H. Life quality impairment caused by hookworm-related cutaneous larva migrans in resource-poor communities in Manaus, Brazil. PLoS Negl Trop Dis. 2011 Nov. 5(11):e1355. [Medline]. [Full Text].
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Reichert F, Pilger D, Schuster A, Lesshafft H, Guedes de Oliveira S, Ignatius R, et al. Prevalence and Risk Factors of Hookworm-Related Cutaneous Larva Migrans (HrCLM) in a Resource-Poor Community in Manaus, Brazil. PLoS Negl Trop Dis. 2016 Mar. 10 (3):e0004514. [Medline].
Sunderkötter C, von Stebut E, Schöfer H, Mempel M, Reinel D, Wolf G, et al. S1 guideline diagnosis and therapy of cutaneous larva migrans (creeping disease). J Dtsch Dermatol Ges. 2014 Jan. 12 (1):86-91. [Medline].
Archer M. Late presentation of cutaneous larva migrans: a case report. Cases J. 2009 Aug 12. 2:7553. [Medline]. [Full Text].
Podder I, Chandra S, Gharami RC. Loeffler’s Syndrome Following Cutaneous Larva Migrans: An Uncommon Sequel. Indian J Dermatol. 2016 Mar-Apr. 61 (2):190-2. [Medline].
Meotti CD, Plates G, Nogueira LL, Silva RA, Paolini KS, Nunes EM, et al. Cutaneous larva migrans on the scalp: atypical presentation of a common disease. An Bras Dermatol. 2014 Mar-Apr. 89 (2):332-3. [Medline].
Aljasser MI, Lui H, Zeng H, Zhou Y. Dermoscopy and near-infrared fluorescence imaging of cutaneous larva migrans. Photodermatol Photoimmunol Photomed. 2013 Dec. 29 (6):337-8. [Medline].
Veraldi S, Angileri L, Parducci BA, Nazzaro G. Treatment of hookworm-related cutaneous larva migrans with topical ivermectin. J Dermatolog Treat. 2017 May. 28 (3):263. [Medline].
Hombu A, Yoshida A, Kikuchi T, Nagayasu E, Kuroki M, Maruyama H. Treatment of larva migrans syndrome with long-term administration of albendazole. J Microbiol Immunol Infect. 2017 Jul 14. [Medline].
Leung AK, Barankin B, Hon KL. Cutaneous larva migrans. Recent Pat Inflamm Allergy Drug Discov. 2017 Jan 10. [Medline].
Kincaid L, Klowak M, Klowak S, Boggild AK. Management of imported cutaneous larva migrans: A case series and mini-review. Travel Med Infect Dis. 2015 Sep-Oct. 13 (5):382-7. [Medline].
Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology. St. Louis, Mo: Mosby; 2003. 1307-09.
David T Robles, MD, PhD Dermatologist, Chaparral Medical Group
David T Robles, MD, PhD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.
Jacquiline Habashy, DO, MSc Resident Physician, Department of Dermatology, Western University of Health Sciences College of Osteopathic Medicine of the Pacific
Jacquiline Habashy, DO, MSc is a member of the following medical societies: American Osteopathic College of Dermatology
Disclosure: Nothing to disclose.
David F Butler, MD Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Society for MOHS Surgery, Association of Military Dermatologists, Phi Beta Kappa
Disclosure: Nothing to disclose.
Edward F Chan, MD Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine
Edward F Chan, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Society for Investigative Dermatology
Disclosure: Nothing to disclose.
William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine
William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology
Disclosure: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD.
Daniel Mark Siegel, MD, MS Clinical Professor of Dermatology, Department of Dermatology, State University of New York Downstate Medical Center
Daniel Mark Siegel, MD, MS is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Association for Physician Leadership, American Society for Dermatologic Surgery, American Society for MOHS Surgery, International Society for Dermatologic Surgery
Disclosure: Nothing to disclose.
Margaret C Douglass, MD Program Director, Department of Dermatology, Henry Ford Hospital
Disclosure: Nothing to disclose.
Lydia A Juzych, MD Senior Staff, Department of Dermatology, Henry Ford Health Sciences Center
Lydia A Juzych, MD is a member of the following medical societies: Alpha Omega Alpha, Michigan State Medical Society, Michigan Dermatological Society, American Medical Association, American Medical Student Association/Foundation, American Medical Womens Association, Phi Beta Kappa
Disclosure: Nothing to disclose.
Cutaneous Larva Migrans
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