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Cutaneous Larva Migrans

Cutaneous larva migrans is a roundworm (usually hookworm) infection. [1] The hosts are cats, dogs and other
animals. Humans normally become infected with the hookworm larvae by walking barefoot on a beach, or by
contact with soil that is contaminated with animal faeces. [2] Infection occurs most commonly in tropical or
subtropical areas. Increase in foreign travel means that it is becoming increasingly common to see cutaneous
larva migrans in the UK.

Aetiology [1, 2]
A number of different roundworms can cause cutaneous larva migrans:

Ancylostoma braziliense: the most common; hosts are wild and domestic dogs and cats; primarily
found in central and southern USA, Central and South America and the Caribbean
Ancylostoma caninum: hosts are dogs; primarily found in Australia.
Uncinaria stenocephala: hosts are dogs; primarily found in Europe.
Bunostomum phlebotomum: hosts are cattle.

Rarely:

Ancylostoma ceylanicum.
Ancylostoma tubaeforme: hosts are cats.
Strongyloides papillosus: hosts are sheep, goats, and cattle.
Strongyloides westeri: hosts are horses.

Nematodes that use humans as a primary host:

Necator americanus.
Ancylostoma duodenale.

NB: cutaneous larva migrans should not be confused with visceral larva migrans and ocular larva migrans which
are different conditions caused by the parasites Toxocara canis or Toxocara cati (common roundworms of dogs
and cats).

Life cycle
Deposited faeces from the animal host can contain hookworm eggs. These hatch in warm, moist,
sandy soil.
Larvae that come into contact with human skin can penetrate through hair follicles, tiny skin cracks or
even intact skin. The larvae then migrate underneath the skin. Unlike in the animal host, the larvae
cannot penetrate the dermis in humans, limiting cutaneous larva migrans to the outer layers of skin.
In animal hosts, penetration of the dermis and passage of the larvae into the venous and lymphatic
system allows transportation to the lungs. Migration to the trachea leads to swallowing of the larvae by
the animal host. There is maturation of the larvae in the intestine, subsequent egg production, and then
excretion in the faeces. This completes the life cycle and allows transmission.
N. americanus, A. duodenale and S. stercoralis are nematodes that use humans as a primary host
and are rare causes of cutaneous larva migrans. With these species, infection can lead to the
completion of the life cycle in humans with adult worms living in the intestines. This can lead to
diarrhoea, malabsorption and malnutrition. [1]

Epidemiology [3]
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[3]
Epidemiology
It can affect all ages but tends to be seen more commonly in children.
Infection occurs most commonly in tropical or subtropical areas. Cutaneous larva migrans is
indigenous to the Caribbean, Central and South America, Africa, and Southeast Asia.

Risk factors
Sunbathing and walking on the beach barefoot.
Children may have been playing in sandpits.
Soil under housing and at construction sites may also be contaminated.

Presentation [1, 2]
In the history taking, ask about recent travel and other risk factors.
The feet, toe web spaces, hands, knees, abdomen, anogenital region and buttocks are the most
common sites of hookworm penetration.
Penetration can cause tingling or prickling of the skin at that site within 30 minutes.
There may be a nonspecific, erythematous skin eruption at the site of hookworm entry.
Larvae can remain dormant for some months but migration can sometimes begin immediately.
Once the larvae begin migration, raised, pink or flesh-coloured, tortuous, snake-like tracks that are 2-3
mm wide form about 3-4 cm from the site of penetration. This is due to an allergic immune response
to the larvae or its byproducts.
Tracts can advance between 2 mm-2 cm per day, depending on the species.
Skin lesions can cause intense pruritus.

Differential diagnosis [4]

Contact dermatitis.
Dermatophytoses.
Erythema chronicum migrans associated with Lyme disease.
Photoallergic dermatitis.
Scabies.

Investigations
Diagnosis is usually clinical. (The Dermatology Information System (DermIS) link below has images of
typical skin changes). [5]
Skin biopsy ahead of the leading tract may show a larva in a burrow and inflammatory infiltrate. [6]
Optical coherence tomography can identify the larvae in the epidermis and allow direct removal. [7]

Management
Cutaneous larva migrans is a self-limiting infection but can be treated with albendazole or ivermectin. [8] Most
cases will resolve within 4-8 weeks because the larvae cannot penetrate the dermis, cannot reproduce, and
eventually die. [2]

Treatment with anthelmintics can shorten the disease course, ease pruritus and lead to resolution of
skin tracts within one week. [2]
Liquid nitrogen cryotherapy for the progressive end of the larval burrow is another alternative
treatment. However, it is painful and multiple treatments are usually needed. [9]
Antihistamines and topical corticosteroids can be added to the treatment to help pruritus.

Complications
Secondary skin infection which may need treatment with antibiotics.
Lffler's disease: this is the combination of pulmonary infiltrates and eosinophilia that can occur with
heavy infestation of larvae. A generalised sensitisation with soluble antigens in the lung causes the
pulmonary infiltrates. [10]
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Prognosis
Cutaneous larva migrans is a self-limiting condition and, without any treatment, most cases will
resolve within 4-8 weeks. [2]

Prevention [1]
Avoiding direct skin contact with contaminated soil - eg, wearing shoes on the beach, and not
sunbathing or sitting directly on sand.
Prohibiting cats and dogs on beaches.
Deworming of pets.
Covering sandpits when not in use.

Further reading & references

1. Heukelbach J, Feldmeier H; Epidemiological and clinical characteristics of hookworm-related cutaneous larva migrans.
Lancet Infect Dis. 2008 May;8(5):302-9.
2. Cutaneous larva migrans; DermNet NZ, Accessed October 2008
3. Simon MW, Simon NP; Cutaneous larva migrans. Pediatr Emerg Care. 2003 Oct;19(5):350-2.
4. Vanhaecke C, Perignon A, Monsel G, et al; Aetiologies of creeping eruption: 78 cases. Br J Dermatol. 2014
May;170(5):1166-9. doi: 10.1111/bjd.12637.
5. Larva Migrans Cutanea; DermIS (Dermatology Information System)
6. Nenoff P, Handrick W, Kruger C, et al; [Ectoparasites. Part 2: Bed bugs, Demodex, sand fleas and cutaneous larva
migrans]. Hautarzt. 2009 Sep;60(9):749-57; quiz 758-9. doi: 10.1007/s00105-009-1821-2.
7. Morsy H, Mogensen M, Thomsen J, et al; Imaging of cutaneous larva migrans by optical coherence tomography. Travel
Med Infect Dis. 2007 Jul;5(4):243-6. Epub 2007 Feb 15.
8. Hookworm; DPDx, Centers for Disease Control and Prevention
9. Kapadia N, Borhany T, Farooqui M; Use of liquid nitrogen and albendazole in successfully treating cutaneous larva
migrans. J Coll Physicians Surg Pak. 2013 May;23(5):319-21. doi: 05.2013/JCPSP.319321.
10. Sen T, Ponde CK, Udwadia ZF; Hypereosinophilic syndrome with isolated Loeffler's endocarditis: complete resolution with
corticosteroids. J Postgrad Med. 2008 Apr-Jun;54(2):135-7.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical
conditions. EMIS has used all reasonable care in compiling the information but makes no warranty as to its
accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions.
For details see our conditions.

Original Author: Current Version: Peer Reviewer:

Dr Michelle Wright Dr Roger Henderson Dr Adrian Bonsall
Document ID: Last Checked: Next Review:
9099 (v3) 11/11/2014 10/11/2019

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