CHAPTER

Cutaneous Larva Migrans

(Creeping Eruption) 164
Presentation
The patient has an intensely pruritic, thin, erythematous, serpiginous, raised eruption on the
sole of the foot, hand, or buttock (Figure 164-1). The patient may remember recently walking
barefoot or sitting in the sand or soil in an area frequented by dogs or cats. Most commonly,
this is seen in travelers returning from tropical or subtropical locations in the Caribbean, Central
America, and South America, as well as in the southeastern United States.

This is a dog or cat hookworm infection. Beaches and sandboxes provide excellent reservoirs
for these parasites. Humans become a dead-end host for the microorganisms by walking
through contaminated areas with bare feet or with open footwear, or by sitting in the tainted
sand or soil.

What To Do:
Prescribe ivermectin (Stromectol), 200 µg/kg, one single dose (supplied as 3-mg
tablet). Alternatively, prescribe albendazole (Albenza), 200 mg PO bid, or 400 mg
qd (supplied as 200-mg tablet or in a 200 mg/mL suspension) × 3 days, or topical
thiabendazole lotion, tid × 7 to 10 days (pharmacist formulated—these dosages are the
same for both adults and pediatric patients).

Although it is only mildly effective, it may still be helpful to prescribe hydroxyzine

(Atarax, Vistaril), 25 to 50 mg qid, or diphenhydramine (Benadryl), 25 to 50 mg qid prn to
reduce itching.

A B
Figure 164-1 A and B, Cutaneous larva migrans. (From White G, Cox N: Diseases of the skin, ed 2. St Louis, 2006, Mosby.)

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What Not To Do:

Do not refer patients for cryotherapy. This was a historic treatment but has been shown to
be ineffective and sometimes locally harmful.

Discussion
This disease is now usually referred to as creeping
eruption, cutaneous larva migrans, or both. To be
more precise, it has been proposed that the term
“hookworm-related cutaneous larva migrans” be
used to describe the cutaneous migration of larvae
of animal hookworms in humans.
These lesions result from infestation by the
skin-penetrating filiform larvae of hookworms
(Ancylostoma braziliense, Ancylostoma caninum,
Uncinaria stenocephala, and others) that hatch
from eggs that are passed in dog and cat feces. If
a human accidentally comes into contact with soil
or sand contaminated by these animal droppings,
these larvae may then penetrate through the skin.
The incidence of this rash is greatest in warm, moist,
sandy areas, such as tropical beaches.
Migration of the larvae at several millimeters per day
results in the characteristic meandering, snakelike
burrows in the epidermis. During larval migration,
a local inflammatory response is provoked, which
causes moderate to intense pruritus. Man is not
the normal host for these parasites, and therefore,
the microorganisms lack the necessary collagenase
to disrupt the basement membrane beneath the
epithelial cells. Therefore the larvae usually die
within 2 to 8 weeks, even without treatment, but
may persist for up to 1 year. Lesions are mostly
localized on the feet, but they also appear on the
buttocks and thighs, trunk, and knees. The diagnosis
of this parasitosis is essentially clinical and relies
entirely on history and physical findings.
The use of topical compounds (e.g.,
10% thiabendazole) is all too frequently
accompanied by irritation, recurrence, and poor
patient compliance. Ivermectin and albendazole,
on the other hand, are effective and fast: 24 to
48 hours are enough to stop the larvae from
migrating, with consequent regression of
pruritus. The skin heals in 2 to 3 weeks, and adverse
reactions are rare. Therefore, although hookworm-
related cutaneous larva migrans is self-limited,
medical treatment shortens the duration and may
prevent complications such as impetigo that results
from scratching.

Suggested Readings

Albanese G, Venturi C: Albendazole: a new drug for human parasitoses, Dermatol Clin 21:283–290, 2003.
Chen TM, Paniker P: An unpleasant memento, Am J Med 118:604–605, 2005.
Caumes E, Danis M: From creeping eruption to hookworm-related cutaneous larva migrans, Lancet 4:659–660, 2004.
del Mar Sáez-De-Ocariz M, McKinster CD, Orozco-Covarrubias L, et al: Treatment of 18 children with scabies or
cutaneous larva migrans using ivermectin, Clin Exp Derm 27:264–267, 2002.
Healy CP, Thomas DE: Leg rash, Am Fam Physician 69:2429–2431, 2004.
Moon TD, Oberhelman RA: Antiparasitic therapy in children, Pediatr Clin North Am 52:917–948, 2005.

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