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Hookworm-related cutaneous larva migrans

Authors: Peter F Weller, MD, MACP, Karin Leder, MBBS, FRACP, PhD, MPH, DTMH
Section Editor: Edward T Ryan, MD, DTMH
Deputy Editor: Elinor L Baron, MD, DTMH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan 2021. | This topic last updated: Jul 29, 2019.

INTRODUCTION

Cutaneous larva migrans (CLM) is a clinical syndrome consisting of an erythematous migrating linear or
serpiginous cutaneous track; an alternative term is creeping eruption.

It most frequently occurs as a result of human infection with the larvae of the dog or cat hookworms,
Ancylostoma braziliense or Ancylostoma caninum; it also may be caused by larvae of other animal
parasites that are not natural human parasites [1].

CLM caused by an animal hookworm is commonly referred to as hookworm-related cutaneous larva

migrans (HrCLM) [2].

Issues related to CLM caused by human infection with larvae of dog or cat hookworms will be reviewed
here. Issues related to human hookworm infection (caused by Ancylostoma duodenale or Necator
americanus) are discussed separately. (See "Hookworm infection".)

EPIDEMIOLOGY

The hookworms responsible for cutaneous larva migrans (CLM) are distributed worldwide; infection is
more frequent in warmer climates, especially in the tropical and subtropical countries of Southeast
Asia, Africa, South America, Caribbean, and the southeastern parts of the United States. Larvae are
found on sandy beaches, in sand boxes, and under dwellings.

Individuals at greatest risk include travelers, children, swimmers, and laborers whose activities bring
their skin in contact with contaminated soil [3,4]. HrCLM is a common cause of dermatologic disease
among those returning from travel in tropical regions [5,6].

In one series of British travelers, infections were acquired most commonly in Africa, the Caribbean,
Southeast Asia, and, less commonly, Central and South America [7]. In another review of Canadian
travelers, infections were acquired most commonly in the Caribbean (most often Jamaica) [8]. In a
review of HrCLM developing in 43 travelers returning to France, infections were acquired in the
Americas (37 percent), Africa (33 percent), Asia (28 percent), and one case in Portugal [9]. In addition,

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HrCLM has occurred in residents of several European countries in the absence of travel to tropical
regions, likely due to local exposures to animal hookworms [9-12]. (See "Skin lesions in the returning
traveler".)

Life cycle — The hookworm life cycle in the definitive host is very similar to the hookworm life cycle for
human species ( figure 1 and figure 2). (See "Hookworm infection".)

Eggs are passed in the stool of the definitive host (adult dog or cat). Under favorable conditions
(moisture, warmth, shade), rhabditiform larvae hatch in 1 to 2 days. After 5 to 10 days (and two molts),
they become filariform (third-stage) larvae, which are infective and can survive 3 to 4 weeks in
favorable environmental conditions.

Upon contact with the nonhuman animal host, the filariform larvae penetrate the skin and are carried
through the blood vessels to the lungs, where they penetrate into the pulmonary alveoli, ascend the
bronchial tree to the pharynx, and are swallowed. The larvae reach the small intestine, where they
reside and mature into adults, which attach to the intestinal wall. Some larvae become arrested in the
tissues and serve as a source of infection for puppies or kittens via transmammary (and possibly
transplacental) routes.

Humans may become infected when filariform larvae in the soil partially penetrate the skin. The larvae
of most species cannot mature within the human host since humans are accidental intermediate hosts.
The larvae migrate within the epidermis and lack the collagenase necessary to break through the
basement membrane [13]. The larvae produce an inflammatory reaction along the cutaneous tract of
their migration, which may continue for weeks.

Some larvae may access deeper tissues. Rarely, pulmonary involvement occurs, either via direct
invasion or secondary to a systemic immunologic reaction [14].

CUTANEOUS DISEASE

HrCLM occurs most frequently on the lower extremities [7,15]. In a report of 98 travelers, lesions most
often involved the lower extremities (73 percent); the buttocks and anogenital region, trunk, and upper
extremities were involved in 13, 7, and 7 percent, respectively [16].

Initially, a pruritic erythematous papule can develop at the site of each larval penetration; many
patients are unaware of the penetration site. With exposure to heavily contaminated soil, up to several
hundred pruritic papules may develop. Within a few days thereafter, intensely pruritic, elevated,
serpiginous, reddish-brown tracks appear as the larvae migrate at a rate of several millimeters (up to a
few centimeters) per day ( picture 1) [17]. The lesions are approximately 3 mm wide and may be up to
15 to 20 mm in length [18], and the larva itself is usually located 1 to 2 cm ahead of the eruption [15].
Usually one to three lesions are present.

Serpiginous lesions usually develop two to six days after exposure but may occur weeks or even many
months after exposure [19-22]. In one review, cutaneous lesions appeared after return from travel with
a mean time of onset of 5 to 16 days [18]. Vesiculobullous lesions develop in about 10 percent of cases
[19,23], and the presence of nodular and bullous lesions may delay the diagnosis [24]. Lesions may
become vesiculated, encrusted, or secondarily infected. The pruritus can be so intense that it causes
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sleep disturbance [8,19,25]. Eventually the lesions resolve spontaneously even in the absence of
specific therapy. This usually occurs in two to eight weeks, although longer duration of infection has
been reported, and cutaneous symptoms may recur days to months later. In one series, 29 percent of
patients had lesions that persisted for one month [16]. Occasionally, larvae persist in follicles and cause
disease for as long as two years [26,27].

Hookworm folliculitis is an uncommon form of HrCLM, occurring in less than 5 percent of cases; it
consists of numerous follicular, erythematous, and pruritic papules and pustules [2]. Serpiginous tracks
may be absent or relatively short [15,28,29].

Diagnosis — The diagnosis of HrCLM is based on clinical history and physical findings. Infected
patients typically have a history of exposure to contaminated soil or sand (walking barefoot or lying on
sand) and the characteristic serpiginous lesion on the skin ( picture 1). Eosinophilia is rare.

There are emerging reports of dermoscopy being used to facilitate diagnosis of CLM; features include
translucent, brown, structureless areas corresponding to the larval bodies, and red-dotted vessels
corresponding to an empty burrow [30].

Ultrasonography may demonstrate subepidermal and intrafollicular structures that are small, linear,
hyperechoic, and hyper-refringent (suggestive of larvae fragments) [31]. Additional findings may
include dermal and hypodermal hypoechoic tunnels with inflammation, reflecting lymphatic duct
dilatation.

Treatment — Anthelminthic therapy for HrCLM is helpful for relieving symptoms and reducing the
likelihood of bacterial superinfection.

Options for treatment include ivermectin or albendazole. The preferred treatment is ivermectin (200
mcg/kg orally once daily for one or two days) [32-34]. A single dose of ivermectin results in cure rates of
94 to 100 percent [18]. Patients with hookworm folliculitis should be treated with two doses of
ivermectin [35,36]. Albendazole (400 mg orally with fatty meal for three days) is an acceptable
alternative treatment. For patients with extensive or multiple lesions, a seven-day course of
albendazole may be administered [37]. Symptoms generally disappear within one week after
treatment; frequently, the pruritus settles before the dermatitis [15].

Treatment of hookworm folliculitis may be difficult, and repeated courses of oral anthelmintic agents
may be required [15].

Topical agents are an alternative treatment option, though they can be difficult to obtain. Topical
thiabendazole (15 percent in a hygroscopic base for five days) is effective in alleviating pruritus and
halting progression of lesions, usually within two days [16,32]. A topical 10% albendazole ointment,
prepared by crushing three 400 mg tablets of albendazole in 12 g of petroleum jelly, has also been
reported to be effective when administered three times daily for 10 days [38].

In addition to antiparasitic agents, antihistamines are helpful for management of pruritus. In patients
with severe allergic reactions, symptomatic treatment with topical corticosteroids may be administered.
(See "Topical corticosteroids: Use and adverse effects".)

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PULMONARY DISEASE

Hematogenous dissemination of larvae to the lungs is a rare complication of infection [14,39-41]. The
most frequent manifestation is dry cough that starts about one week after cutaneous penetration. The
cough usually lasts for one to two weeks but may rarely persist for up to nine months.

Diagnosis — A presumptive diagnosis of pulmonary involvement in cutaneous larva migrans is made

when respiratory symptoms develop in the presence of the typical cutaneous lesions. Further
diagnostic evaluation is not usually necessary.

Chest radiography may demonstrate transient migratory infiltrates ( image 1) [42,43]. Blood
eosinophilia is common, and bronchoalveolar lavage may also demonstrate eosinophils. Definitive
diagnosis consists of recovery of larvae from respiratory secretions or bronchoalveolar lavage fluid,
although such procedures are rarely needed.

Stool examination and serologic tests are not helpful.

Treatment — Specific anthelminthic therapy for the pulmonary involvement is generally not required
since the illness is usually mild and self-limited.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of HrCLM includes:

● Strongyloidiasis – The main differential diagnosis of a creeping eruption is the larva currens
("running" larva) of strongyloidiasis [44]. Larva currens has a prominent urticarial component and
is notable for its rapidity. The larval track of larva currens can progress approximately 1 cm in five
minutes and 5 to 15 cm per hour; the larval track of HrCLM can progress up to 1 to 2 cm per day.
The diagnosis of strongyloidiasis is established by larva detection and/or serology. (See
"Strongyloidiasis".)

● Gnathostomiasis – Migrating Gnathostoma larvae cause localized swellings that typically last one to
two weeks and are associated with edema, pain, itching, and erythema. The diagnosis is
established by larva detection and/or serology. (See "Skin lesions in the returning traveler", section
on 'Gnathostomiasis'.)

● Loiasis – Loiasis is associated with transient localized subcutaneous swellings (known as Calabar
swellings); typically, they are nonerythematous and measure 5 to 20 cm in diameter. The diagnosis
is established by visualization of organisms or via serology. (See "Loiasis (Loa loa infection)",
section on 'Calabar swellings'.)

● Dracunculiasis – Dracunculiasis is associated with migration of worms in the subcutaneous tissues,

followed by development of a painful papule and emergence of one or more worms accompanied
by a burning sensation. The diagnosis is based on clinical manifestations. (See "Miscellaneous
nematodes", section on 'Dracunculiasis'.)

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● Paragonimiasis – Paragonimiasis can be associated with painless, migratory subcutaneous

swellings of various sizes or tender, firm mobile nodules containing immature flukes. The diagnosis
is established via serology. (See "Paragonimiasis", section on 'Subcutaneous infection'.)

● Fascioliasis – Ectopic fascioliasis results in eosinophilic and mononuclear infiltration with secondary
tissue damage. The most common ectopic site is the subcutaneous tissue of the abdominal wall.
Tender, migrating, erythematous, itchy nodules (1 to 6 cm in diameter) can develop. (See "Liver
flukes: Fascioliasis", section on 'Ectopic fascioliasis'.)

Other causes of non-migratory skin lesions include:

● Tinea pedis – Acute tinea pedis consists of intensely pruritic, sometimes painful, erythematous
vesicles or bullae between the toes or on the soles, frequently extending up the instep. The
diagnosis can be confirmed by potassium hydroxide examination of scrapings from the lesions.
(See "Dermatophyte (tinea) infections", section on 'Tinea pedis'.)

● Contact dermatitis – Contact dermatitis is a localized inflammatory skin response to a range of

chemical or physical agents. Clinical features include erythema, edema, vesicles, and bullae; lesions
are typically pruritic. The diagnosis is established by history and physical examination. (See "Irritant
contact dermatitis in adults".)

● Impetigo – Impetigo is a superficial bacterial infection of the skin. Lesions progress from papules
to vesicles surrounded by erythema; subsequently, they become pustules that rapidly break down
to form crusts with a characteristic golden appearance. Lesions are typically painful. The diagnosis
is established by history and physical examination. (See "Impetigo".)

● Myiasis – Myiasis due to the botfly or tumbu fly consists of skin lesions containing fly larvae; the
lesions enlarge over time but are not migratory and the organism can be visualized moving within
the lesion. The diagnosis is established by history and physical examination. (See "Skin lesions in
the returning traveler", section on 'Myiasis'.)

● Scabies – Scabies is an infestation of the skin by the mite Sarcoptes scabiei. Scabies usually
manifests as small, erythematous, nondescript papules or as thin, linear burrows and most
commonly involves the sides and webs of the fingers (interdigital spaces); it can be intensely
pruritic. The diagnosis is usually established by history and physical examination. (See "Scabies:
Epidemiology, clinical features, and diagnosis".)

SUMMARY AND RECOMMENDATIONS

● Cutaneous larva migrans (CLM) occurs most commonly as a result of human infection with the
larvae of the dog or cat hookworm; it may also be caused by other animal hookworms (hookworm-
related cutaneous larva migrans [HrCLM]). The terms CLM and "creeping eruption" refer to
subcutaneous intradermal migration of nonhuman filariform zoonotic larvae that may manifest as
a cutaneous track. (See 'Introduction' above.)

● Infection occurs most frequently in the tropical and subtropical countries of Southeast Asia, Africa,
South America, Caribbean, and the southeastern parts of the United States. Larvae are found on

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sandy beaches, in sand boxes, and under dwellings. Individuals at greatest risk include travelers,
children, swimmers, and laborers whose activities bring their skin in contact with contaminated
soil. (See 'Epidemiology' above.)

● The hookworm life cycle in the definitive host is very similar to the hookworm life cycle for human
species ( figure 1 and figure 2). Humans may become infected when filariform larvae in the
soil penetrate the skin. The larvae of most species cannot mature within the human host; they
migrate within the epidermis and produce an inflammatory reaction. (See 'Life cycle' above.)

● HrCLM occurs most frequently on the lower extremities. Initially, a pruritic erythematous papule
develops at the site of each larval penetration. Two to three days later, intensely pruritic, elevated,
serpiginous, reddish-brown lesions appear as the larvae migrate at a rate of several millimeters per
day ( picture 1). The lesions generally resolve spontaneously within two to eight weeks in the
absence of specific therapy. (See 'Cutaneous disease' above.)

● We suggest treatment of HrCLM with anthelminthic therapy (Grade 2C); treatment is helpful for
relieving symptoms and reducing the likelihood of bacterial superinfection. We suggest systemic
treatment with either ivermectin (200 mcg/kg orally once daily for one or two days) or albendazole
(400 mg orally with fatty meal for three days) (Grade 2C). Topical agents are an alternative
treatment option though they can be difficult to obtain and use. (See 'Treatment' above.)

● Hematogenous dissemination of larvae to the lungs is rare. The most frequent manifestation is dry
cough that starts about one week after cutaneous penetration. Specific anthelminthic therapy for
the pulmonary involvement is generally not required since the illness is usually mild and self-
limited. (See 'Pulmonary disease' above.)

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14. Tan SK, Liu TT. Cutaneous larva migrans complicated by Löffler syndrome. Arch Dermatol 2010;
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15. Hochedez P, Caumes E. Hookworm-related cutaneous larva migrans. J Travel Med 2007; 14:326.
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17. Caumes E, Danis M. From creeping eruption to hookworm-related cutaneous larva migrans. Lancet
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20. Archer M. Late presentation of cutaneous larva migrans: a case report. Cases J 2009; 2:7553.
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29. Rivera-Roig V, Sánchez JL, Hillyer GV. Hookworm folliculitis. Int J Dermatol 2008; 47:246.
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37. Veraldi S, Rizzitelli G. Effectiveness of a new therapeutic regimen with albendazole in cutaneous
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38. Caumes E. Efficacy of albendazole ointment on cutaneous larva migrans in 2 young children. Clin
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GRAPHICS

Intestinal hookworm infection life cycle

Eggs are passed in the stool (1), and under favorable conditions (moisture, warmth, shade) larvae hatch in one
to two days. The released rhabditiform larvae grow in the feces and/or the soil (2), and after 5 to 10 days (and two
molts) they become filariform (third-stage) larvae that are infective (3). These infective larvae can survive three
to four weeks in favorable environmental conditions. On contact with the human host, the larvae penetrate the
skin and are carried through the blood vessels to the heart and then to the lungs. They penetrate into the
pulmonary alveoli, ascend the bronchial tree to the pharynx, and are swallowed (4). The larvae reach the small
intestine, where they reside and mature into adults. Adult worms live in the lumen of the small intestine, where
they attach to the intestinal wall with resultant blood loss by the host (5). Most adult worms are eliminated in one
to two years, but the longevity may reach several years. Some Ancylostoma duodenale larvae, following penetration
of the host skin, can become dormant (in the intestine or muscle). In addition, infection by A. duodenale may
probably also occur by the oral and transmammary route. Necator americanus, however, requires a transpulmonary
migration phase.

Reproduced from: Centers for Disease Control and Prevention. DPDx: Hookworm. http://www.cdc.gov/dpdx/hookworm/index.html.

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Cutaneous larva migrans life cycle

Cutaneous larval migrans (also known as creeping eruption) is a zoonotic infection with hookworm species that
do not use humans as a definitive host, the most common being Ancylostoma braziliense and Ancylostoma
caninum. The normal definitive hosts for these species are dogs and cats. The cycle in the definitive host is very
similar to the cycle for the human species. Eggs are passed in the stool (1), and under favorable conditions
(moisture, warmth, shade) larvae hatch in one to two days. The released rhabditiform larvae grow in the feces
and/or the soil (2), and after 5 to 10 days (and two molts) they become filariform (third-stage) larvae that are
infective (3). These infective larvae can survive three to four weeks in favorable environmental conditions. On
contact with the animal host (4), the larvae penetrate the skin and are carried through the blood vessels to the
heart and then to the lungs. They penetrate into the pulmonary alveoli, ascend the bronchial tree to the pharynx,
and are swallowed. The larvae reach the small intestine, where they reside and mature into adults. Adult worms
live in the lumen of the small intestine, where they attach to the intestinal wall. Some larvae become arrested in
the tissues and serve as source of infection for pups via transmammary (and possibly transplacental) routes (5).
Humans may also become infected when filariform larvae penetrate the skin (6). With most species, the larvae
cannot mature further in the human host and migrate aimlessly within the epidermis, sometimes as much as
several centimeters a day. Some larvae may persist in deeper tissue after finishing their skin migration.

Reproduced from: Centers for Disease Control and Prevention. DPDx: Hookworm. Available at:
http://www.cdc.gov/dpdx/hookworm/index.html.

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Cutaneous larva migrans

Reproduced with permission from Jeremy Driscoll, MD, Carolinas Medical Center.

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Chest radiograph - pulmonary involvement of cutaneous larva

migrans

Posteroanterior chest radiograph showing bilaterial reticulonodular infiltrates.

Reproduced from: Mackowiak PA. A rash and cough in a traveler. Clin Infect Dis 2011; 53:167, by
permission of Oxford University Press. Copyright © 2011.

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Contributor Disclosures
Peter F Weller, MD, MACP Grant/Research/Clinical Trial Support: GlaxoSmithKline [Anti-IL5 mAb for EGPA].
Consultant/Advisory Boards: Knopp Biosciences [Hypereosinophilic syndrome treatment]; GlaxoSmithKline
[Eosinophilic diseases]; Genzyme [Eosinophilia]. Other Financial Interest: AstraZeneca [Hypereosinophilic
syndrome]. Karin Leder, MBBS, FRACP, PhD, MPH, DTMH Nothing to disclose Edward T Ryan, MD,
DTMH Grant/Research/Clinical Trial Support: Sanofi [Yellow fever]. Elinor L Baron, MD, DTMH Nothing to disclose

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addressed by vetting through a multi-level review process, and through requirements for references to be
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