Practice Essentials

Cutaneous larva migrans (CLM) is a serpiginous eruption usually confined to the skin of the feet, buttocks, or abdomen caused by dog and cat hookworms, which are types of nematodes (roundworms).^[1]Skin findings are due to a hypersensitivity reaction to the worms and their byproducts.^{[2, 3]}

Although CLM can occur in the temperate zones in the warmer months of the year, infection is most commonly found in tropical and subtropical climates. Modern ease of travel necessitates inclusion of CLM in the differential diagnosis of serpiginous pruritic lesions, regardless of the location of practice.^{[4, 5]}See the images below.

Cutaneous larva migrans involving the foot with erythematous, edematous, serpiginous tracks. Infestation has caused a cellulitis.

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Cutaneous larva migrans involving the dorsal foot. Graphic courtesy of Dr Sara K. Ward.

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Pathophysiology

Larvae from animal nematodes that infect humans usually cause CLM. The normal hosts for these hookworms are cats and dogs, in which the roundworm eggs pass through the feces. The eggs optimally hatch in warm, shady, moist, sandy soil found in tropical and subtropical areas. Humans are infected with the larvae by walking barefoot on the sand. The larvae quickly penetrate the skin upon contact.

Beaches are the most common reservoir for the larvae that cause CLM; however, infection can occur from sandboxes and soil under houses or at construction sites.^[6]The prohibition of dogs and cats on beaches is a way to limit transmission of the infection.

Frequency

United States

Exact incidence is unknown; however, Jelinek et al reported that 6.7% of the 13,300 travelers visiting a travel-related disease clinic presented with CLM.^[7]In the United States, most cases occur in eastern and southern coastal areas from New Jersey to Texas. The highest incidence is in Florida.

International

Worldwide distribution is predominantly reported in tropical zones, although cases acquired in France and Portugal illustrate the broad distribution of the causative organisms.^{[8, 9]}CLM is indigenous to the Caribbean, Central and South America,^[10]Africa, Southeast Asia, and Australia.^[11]

Mortality/Morbidity

Mortality from the infection is not reported. Most episodes of CLM resolve with or without treatment and with no long-term adverse consequences. Morbidity is associated with an intensely pruritic rash, which leads to secondary impetiginization and cellulitis. In rare incidents of CLM in which nematodes use a human as a definitive host, infection can lead to the completion of the nematode life cycle with adult worms residing in the intestines. This causes diarrhea, malabsorption, and malnutrition.

Race

CLM has no racial predilection.

Sex

No sex predilection is observed.

Age

CLM affects all ages in the appropriate environment.

Clinical Presentation

Brenner MA, Patel MB. Cutaneous larva migrans: the creeping eruption. Cutis. 2003 Aug. 72(2):111-5. [Medline].
Feldmeier H, Schuster A. Mini review: hookworm-related cutaneous larva migrans. Eur J Clin Microbiol Infect Dis. 2011 Sep 16. [Medline].
Purdy KS, Langley RG, Webb AN, Walsh N, Haldane D. Cutaneous larva migrans. Lancet. 2011 Jun 4. 377(9781):1948. [Medline].
Criado PR, Belda W Jr, Vasconcellos C, Silva CS. Cutaneous larva migrans: a bad souvenir from the vacation. Dermatol Online J. 2012 Jun 15. 18(6):11. [Medline].
Gautret P, Cramer JP, Field V, et al. Infectious diseases among travellers and migrants in Europe, EuroTravNet 2010. Euro Surveill. 2012 Jun 28. 17(26):[Medline].
Traversa D, Frangipane di Regalbono A, Di Cesare A, La Torre F, Drake J, Pietrobelli M. Environmental contamination by canine geohelminths. Parasit Vectors. 2014 Feb 13. 7:67. [Medline]. [Full Text].
Jelinek T, Maiwald H, Nothdurft HD, Loscher T. Cutaneous larva migrans in travelers: synopsis of histories, symptoms, and treatment of 98 patients. Clin Infect Dis. 1994 Dec. 19(6):1062-6. [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].
Sow D, Soro F, Javelle E, Simon F, Parola P, Gautret P. Epidemiological profile of cutaneous larva migrans in travelers returning to France between 2003 and 2015. Travel Med Infect Dis. 2017 Nov - Dec. 20:61-64. [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].
Black MD, Grove DI, Butcher AR, Warren LJ. Cutaneous larva migrans in infants in the Adelaide Hills. Australas J Dermatol. 2010 Nov. 51(4):281-4. [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].
Butland RJ, Coulson IH. Pulmonary eosinophilia associated with cutaneous larva migrans. Thorax. 1985 Jan. 40(1):76-7. [Medline].
Morsy H, Mogensen M, Thomsen J, Thrane L, Andersen PE, Jemec GB. Imaging of cutaneous larva migrans by optical coherence tomography. Travel Med Infect Dis. 2007 Jul. 5(4):243-6. [Medline].
Veraldi S, Bottini S, Rizzitelli G, Persico MC. One-week therapy with oral albendazole in hookworm-related cutaneous larva migrans: A retrospective study on 78 patients. J Dermatolog Treat. 2011 Feb 6. [Medline].
Vanhaecke C, Perignon A, Monsel G, Regnier S, Bricaire F, Caumes E. The efficacy of single dose ivermectin in the treatment of hookworm related cutaneous larva migrans varies depending on the clinical presentation. J Eur Acad Dermatol Venereol. 2014 May. 28 (5):655-7. [Medline].
Tan SK, Liu TT. Cutaneous larva migrans complicated by Löffler syndrome. Arch Dermatol. 2010 Feb. 146(2):210-2. [Medline].
Wright DO, Gold EM. Loeffler's syndrome associated with creeping eruption (cutaneous helminthiasis). Arch Intern Med. 1946. 78:303-12.
Burkhart CG, Burkhart CN. Cutaneous larva migrans complicated by erythema multiforme. Cutis. 1998 Oct. 62(4):170. [Medline].
American Academy of Pediatrics. Cutaneous Larva Migrans. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th. Elk Grove Village, IL: American Academy of Pediatrics; 2009. 274.
Ang CC. Images in clinical medicine. Cutaneous larva migrans. N Engl J Med. 2010 Jan 28. 362(4):e10. [Medline].
Ansart S, Perez L, Jaureguiberry S, et al. Spectrum of dermatoses in 165 travelers returning from the tropics with skin diseases. Am J Trop Med Hyg. 2007 Jan. 76(1):184-6. [Medline].
Cutaneous Larva Migrans. Spector JM, Gibson TE. Atlas of Pediatrics in the Tropics and Resource-Limited Settings. Elk Grove Village, IL: American Academy of Pediatrics; 2009. 69-71.
Berlin JM, Goldberg SJ, McDonough RD, Leeman DR. JAAD Grand Rounds quiz. Serpiginous eruption on the leg. J Am Acad Dermatol. 2010 Nov. 63(5):921-2. [Medline].
Bouchaud O, Houze S, Schiemann R, et al. Cutaneous larva migrans in travelers: a prospective study, with assessment of therapy with ivermectin. Clin Infect Dis. 2000 Aug. 31(2):493-8. [Medline].
Caumes E. It's time to distinguish the sign 'creeping eruption' from the syndrome 'cutaneous larva migrans'. Dermatology. 2006. 213(3):179-81. [Medline].
Caumes E, Carriere J, Datry A, et al. A randomized trial of ivermectin versus albendazole for the treatment of cutaneous larva migrans. Am J Trop Med Hyg. 1993 Nov. 49(5):641-4. [Medline].
Cayce KA, Scott CM, Phillips CM, Frederick C, Park HK. What is your diagnosis? Cutaneous larva migrans. Cutis. 2007 Jun. 79(6):429, 435-6. [Medline].
Chaudhry AZ, Longworth DL. Cutaneous manifestations of intestinal helminthic infections. Dermatol Clin. 1989 Apr. 7(2):275-90. [Medline].
Craythorne EE, Wong S, Jones RM, du Vivier AW. A characteristic rash. BMJ. 2009 May 20. 338:b1451. [Medline].
Cutaneous larva migrans in American tourists. Martinique and Mexico. MMWR Morb Mortal Wkly Rep. 1981 Jul 3. 30(25):308, 313. [Medline].
Davies HD, Sakuls P, Keystone JS. Creeping eruption. A review of clinical presentation and management of 60 cases presenting to a tropical disease unit. Arch Dermatol. 1993 May. 129(5):588-91. [Medline].
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].
Elsner E, Thewes M, Worret WI. Cutaneous larva migrans detected by epiluminescent microscopy [letter]. Acta Derm Venereol. 1997 Nov. 77(6):487-8. [Medline].
Feldmeier H, Heukelbach J. Epidermal parasitic skin diseases: a neglected category of poverty-associated plagues. Bull World Health Organ. 2009 Feb. 87(2):152-9. [Medline]. [Full Text].
Fleischer LM, Cataldo R, Syed SS. Visual diagnosis: a 10-year-old boy who has a pruritic rash after travel. Pediatr Rev. 2008 Nov. 29(11):407-9. [Medline].
Ghosh SK, Bandyopadhyay D. Dermacase: Can you identify this condition? Cutaneous larva migrans. Can Fam Physician. 2009 May. 55(5):489, 491. [Medline]. [Full Text].
Grassi A, Angelo C, Grosso MG, Paradisi M. Perianal cutaneous larva migrans in a child. Pediatr Dermatol. 1998 Sep-Oct. 15(5):367-9. [Medline].
Hardin TF Jr. Management of cutaneous larva migrans in pediatric practice: report on 200 cases. J Am Osteopath Assoc. 1969 May. 68(9):970-2. [Medline].
Herbinger KH, Siess C, Nothdurft HD, von Sonnenburg F, Löscher T. Skin disorders among travellers returning from tropical and non-tropical countries consulting a travel medicine clinic. Trop Med Int Health. 2011 Jul 18. [Medline].
Heukelbach J, Feldmeier H. Epidemiological and clinical characteristics of hookworm-related cutaneous larva migrans. Lancet Infect Dis. 2008 May. 8(5):302-9. [Medline].
Heukelbach J, Hengge UR. Bed bugs, leeches and hookworm larvae in the skin. Clin Dermatol. 2009 May-Jun. 27(3):285-90. [Medline].
Hotez PJ, Brooker S, Bethony JM, et al. Hookworm infection. N Engl J Med. 2004 Aug 19. 351(8):799-807. [Medline].
Jensenius M, Maeland A, Brubakk O. Extensive hookworm-related cutaneous larva migrans in Norwegian travellers to the tropics. Travel Med Infect Dis. 2008 Jan-Mar. 6(1-2):45-7. [Medline].
Joncour AL, Lacour SA, Lecso G, Regnier S, Guillot J, Caumes E. Molecular Characterization of Ancylostoma braziliense Larvae in a Patient with Hookworm-Related Cutaneous Larva Migrans. Am J Trop Med Hyg. 2012 May. 86(5):843-845. [Medline].
Kahn G, Johnson JA. Serum IGE levels in cutaneous Larva Migrans. Int J Dermatol. 1971 Jul-Sep. 10(3):201-3. [Medline].
Kaminska-Winciorek G, Pierzchala E, Brzezinska-Wcislo L. Cutaneous larva migrans syndrome: clinical and ultrasonographic picture of the skin lesions. Eur J Dermatol. 2007 May-Jun. 17(3):246-7. [Medline].
Kelkar R. Cutaneous larva migrans in England: a case in a returning traveller. Emerg Med J. 2007 Sep. 24(9):678. [Medline].
Kienast A, Bialek R, Hoeger PH. Cutaneous larva migrans in northern Germany. Eur J Pediatr. 2007 Jan 10. [Medline].
Kim TH, Lee BS, Sohn WM. Three clinical cases of cutaneous larva migrans. Korean J Parasitol. 2006 Jun. 44(2):145-9. [Medline].
Lederman ER, Weld LH, Elyazar IR, et al. Dermatologic conditions of the ill returned traveler: an analysis from the GeoSentinel Surveillance Network. Int J Infect Dis. 2008 Nov. 12(6):593-602. [Medline].
Lee AC, Schantz PM, Kazacos KR, Montgomery SP, Bowman DD. Epidemiologic and zoonotic aspects of ascarid infections in dogs and cats. Trends Parasitol. 2010 Apr. 26(4):155-61. [Medline].
Lemery J. Images in emergency medicine. Cutaneous larvae migrans. Ann Emerg Med. 2008 Jul. 52(1):82, 92. [Medline].
Lesniak R. Cutaneous larva migrans. Dermatol Nurs. 2008 Dec. 20(6):471-2. [Medline].
Loughrey MB, Irvine AD, Girdwood RW, McMillan JC. Cutaneous larva migrans: the case for routine oral treatment [letter]. Br J Dermatol. 1997 Jul. 137(1):155-6. [Medline].
Mattone-Volpe F. Cutaneous larva migrans infection in the pediatric foot. A review and two case reports. J Am Podiatr Med Assoc. 1998 May. 88(5):228-31. [Medline].
Micantonio T, Peris K. What is your call?: pruritic, serpiginous eruption in a returning traveller. CMAJ. 2008 Jul 1. 179(1):51-2. [Medline].
Monsel G, Caumes E. Recent developments in dermatological syndromes in returning travelers. Curr Opin Infect Dis. 2008 Oct. 21(5):495-9. [Medline].
Morrone A, Franco G, Fazio R, Valenzano M, Calcaterra R. Bullous cutaneous larva migrans. Acta Dermatovenerol Croat. 2011 Jun. 19(2):120-1. [Medline].
Novak KD, Williams SM, Kokot I, Schultze RL. Nd:YAG photodestruction of a presumed corneal Toxocara canis larva. Cornea. 2010 Jun. 29(6):703-5. [Medline].
O'Brien BM. A practical approach to common skin problems in returning travellers. Travel Med Infect Dis. 2009 May. 7(3):125-46. [Medline].
O'Quinn JC, Dushin R. Cutaneous larva migrans: case report with current recommendations for treatment. J Am Podiatr Med Assoc. 2005 May-Jun. 95(3):291-4. [Medline].
Ottesen EA, Campbell WC. Ivermectin in human medicine. J Antimicrob Chemother. 1994 Aug. 34(2):195-203. [Medline].
Outbreak of cutaneous larva migrans at a children's camp--Miami, Florida, 2006. MMWR Morb Mortal Wkly Rep. 2007 Dec 14. 56(49):1285-7. [Medline].
Patel S, Sethi A. Imported tropical diseases. Dermatol Ther. 2009 Nov-Dec. 22(6):538-49. [Medline].
Puente Puente S, Bru Gorraiz F, Azuara Solis M, et al. [Cutaneous larva migrans: 34 outside cases]. Rev Clin Esp. 2004 Dec. 204(12):636-9. [Medline].
Rao R, Prabhu S, Sripathi H. Cutaneous larva migrans of the genitalia. Indian J Dermatol Venereol Leprol. 2007 Jul-Aug. 73(4):270-1. [Medline].
Reavis M, Jorgensen S. Acute pruritic rash on the foot. Cutaneous larva migrans. Am Fam Physician. 2010 Jan 15. 81(2):203. [Medline].
Rizzitelli G, Scarabelli G, Veraldi S. Albendazole: a new therapeutic regimen in cutaneous larva migrans. Int J Dermatol. 1997 Sep. 36(9):700-3. [Medline].
Rubinsky-Elefant G, Hirata CE, Yamamoto JH, Ferreira MU. Human toxocariasis: diagnosis, worldwide seroprevalences and clinical expression of the systemic and ocular forms. Ann Trop Med Parasitol. 2010 Jan. 104(1):3-23. [Medline].
Sanchez Fernandez I, Julia Manresa M, Gonzalez Ensenat MA, Vicente Villa MA. Picture of the month--quiz case. Bullous cutaneous larva migrans. Arch Pediatr Adolesc Med. 2008 May. 162(5):485-6. [Medline].
Senba Y, Tsuda K, Maruyama H, Kurokawa I, Mizutani H, Taniguchi Y. Case of creeping disease treated with ivermectin. J Dermatol. 2009 Feb. 36(2):86-9. [Medline].
Shih PY, Hsieh MY, Huang YH, Kuo TT. Multiple pruritic erythematous papules on the trunk after a trip to Thailand--quiz case. Arch Dermatol. 2010 May. 146(5):557-62. [Medline].
Shinkar RM, Stocks R, Thomas E. Cutaneous larva migrans, creeping eruption, sand worm. Arch Dis Child. 2005 Oct. 90(10):998. [Medline].
Siriez JY, Angoulvant F, Buffet P, Cleophax C, Bourrat E. Individual variability of the cutaneous larva migrans (CLM) incubation period. Pediatr Dermatol. 2010 Mar 1. 27(2):211-2. [Medline].
Stoicescu RM, Mihai CM, Giannakopoulou AD. Marked hypereosinophilia in a toddler: a case report. J Med Life. 2011 Jan-Mar. 4(1):105-8. [Medline]. [Full Text].
The Medical Letter. Drugs for Parasitic Infections. Medical Letter On Drugs and Therapeutics. Available at http://secure.medicalletter.org/TG-article-89b.
Van den Enden E, Stevens A, Van Gompel A. Treatment of cutaneous larva migrans [letter; comment]. N Engl J Med. 1998 Oct 22. 339(17):1246-7. [Medline].
Vaughan TK, English JC 3rd. Cutaneous larva migrans complicated by erythema multiforme. Cutis. 1998 Jul. 62(1):33-5. [Medline].
Veraldi S, Rizzitelli G. Effectiveness of a new therapeutic regimen with albendazole in cutaneous larva migrans. Eur J Dermatol. 1999 Jul-Aug. 9(5):352-3. [Medline].
Yap FB. Creeping eruption. Int J Infect Dis. 2010 Jun. 14(6):e545. [Medline].

Media Gallery

Cutaneous larva migrans involving the foot with erythematous, edematous, serpiginous tracks. Infestation has caused a cellulitis.
Cutaneous larva migrans involving the dorsal foot. Graphic courtesy of Dr Sara K. Ward.

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Author

Martha L Muller, MD, MPH Professor of Pediatrics, Division of Infectious Diseases, University of New Mexico School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Martin Weisse, MD Program Director, Associate Professor, Department of Pediatrics, West Virginia University

Martin Weisse, MD is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Michael D Nissen, MBBS FRACP, FRCPA, Associate Professor in Biomolecular, Biomedical Science & Health, Griffith University; Director of Infectious Diseases and Unit Head of Queensland Paediatric Infectious Laboratory, Sir Albert Sakzewski Viral Research Centre, Royal Children's Hospital

Michael D Nissen, MBBS is a member of the following medical societies: American Academy of Pediatrics, Royal College of Pathologists of Australasia, Royal Australasian College of Physicians, American Society for Microbiology, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Acknowledgements

Jining Wang, MD Department of Dermatology, Dean Health System

Jining Wang, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Kim Wang, MD Staff Physician, Department of Pathology, Northwestern University Medical School

Kim Wang, MD is a member of the following medical societies: United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.