Creeping Eruption - Een Verdieping in Huidaandoeningen

Conclusion

The present data illustrate the clustering of six cases successively in winter season. It may be due to the increased hookworm infection in stray animals accelerated by behavioral and environmental factors. As change in the climatic conditions is not possible, only an integral approach combining the health education and control of the animal reservoirs can be the effective strategy for controlling CLM.

What is new?

Though CLM is generally linked with tropical areas, this report on six cases from non- endemic area is an alarming sign for further exploration of both behavioral and environmental factors. All six patient presented during winter season (average temperatures around 12.13° C/54.55° F) and the type of soil, both of which are not suitable for the appropriate growth of nematode. Two patients presented with characteristic lesion of CLM on face which is considered to be the least common site in the literature..

De kleur rood aan de voeten

Veel huidziekten gaan gepaard met roodheid. Dit is de meest voorkomende kleur aan de voet met een veelheid aan mogelijkheden. Roodheid berust vooral op de doorbloeding van de huid. Bij een rode kleur moet men zich afvragen: is er alleen maar een rode kleur of is er meer aan de hand, zoals schilfering of blaasjes? Gaat roodheid gepaard met schilfering dan is er een epidermale component aanwezig, dat wil zeggen dat de epidermis (= opperhuid) meedoet. Dat is bijvoorbeeld het geval bij een schimmelinfectie, psoriasis of eczeem. Bij eczeem kunnen ook blaasjes aanwezig zijn. Wanneer alleen roodheid aanwezig is bij een intacte gladde huid, dan kunnen er diverse onderliggende mogelijkheden zijn. Er kan sprake zijn van vaatlijden, van een infectie of van een ontsteking van de huid of dieper gelegen structuren zoals een onderliggend gewricht. Pijn of koorts kunnen alarmerende symptomen zijn.

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Optimal Therapeutic Approach for this Disease

The primary role of active treatment for CLM is to provide rapid symptomatic improvement (ie. severe pruritus and discomfort) and secondary complications (ie. cellulitis, autoinfection, etc.). Pruritus usually settles within 24-72 hours of treatment. The cutaneous lesions tend to resolve within 1-2 weeks. Even without any treatment, CLM will resolve within weeks to months in almost all infected individuals but can persist for up to 2 years. The larvae eventually die in human hosts since they cannot complete their lifecycle (ie. dead-end hosts).

The treatment of choice is oral albendazole (a third-generation anthelminth agent). Other anthelmintics such as thiabendazole and mebendazole are also effective. Albendazole is relatively well tolerated, whereas thiabendazole has been associated with a higher incidence of gastrointestinal symptoms (ie. nausea, diarrhea). If compliance is an issue, a single dose of ivermectin can be used with high cure rates.

The efficacy of cryotherapy is variable and not usually recommended. Larvae are able to survive in –20° C for more than 5 minutes. Aggressive cryotherapy is painful and can result in large bullae and ulcer formation.

It is also important to examine and treat the patient for a secondary soft tissue infection or cellulitis. Treatment with oral antibiotics would be appropriate.

Prevention is the most important factor. Persons traveling to high-risk tropical or subtropical beaches should be encouraged to wear appropriate protective footwear or sit on towels. Pet owners should also be educated and ensure that their pets receive the appropriate treatment if infected. In the future, hookworm vaccines may be available. A topical analgesic such as pramoxine could be of benefit.

Discussion

Uncommon clinical presentations of CML include [2, 4, 13, 14, 17]:

The complications of cutaneous larva migrans include secondary bacterial infections, local or general allergic reactions and very rarely parasite's migration to internal organs [2, 7, 10, 11, 13].

Effective treatment of hookworm-related CML is based on oral or topical antihelminthics. Ivermectin, albendazole and tiabendazole are drugs, which are acceptable for systemic treatment. First-line treatment are ivermectin and albendazole. Ivermectin is well tolerated and highly effective but contraindicated in children younger than 5 years [14]. It is taken at a single dose of 200 µg/kg, while the average dose is 12 mg. Albendazole is also efficient at a daily dosage between 400 mg and 800 mg for 1 to 7 days. Thiabendazole is not recommended because of a relatively high incidence of the following side effects: dizziness, nausea, vomiting and intestinal cramps [6, 7, 14]. In cases when oral drugs are contraindicated, ointments with 10% albendazole or 10-15% thiabendazole should be considered [18]. Topical application of ointment 3 times daily for 5 to 10 days on the affected skin is comparable to the oral treatment for CML [14, 18]. Nowadays, physical modalities such as cryotherapy with carbon dioxide or liquid nitrogen are used in exceptional cases [1, 8, 11, 13, 15]. The response to an antihelmintic drug and rapid resolution of the lesion confirmed the initial diagnosis of cutaneous larva migrans [13, 15].

Traveling has become accessible and universal among people in the world leading to an increase in the number of tropical dermatosis e.g. cutaneous larva migrans. Nowadays, health education should be focused on tourists, who are planning a trip to hot zone countries, endemic areas for CML. They should be advised to wear shoes in sandy areas, to use deckchairs or mattresses on beaches and to avoid beaches where animals are present.

Systemic Implications and Complications

Systemic complications are uncommon, but can occasionally occur. Loeffler’s syndrome, considered a rare hypersensitivity response to soluble hookworm antigen, manifests as eosinophilic migratory pulmonary infiltrates. Notably, peripheral eosinophilia with elevated immunoglobulin E (IgE) can also occur with any parasitic infection.

• Oral albendazole is considered the treatment of choice. Dosage: 400-800mg daily (adults), 10-15 mg/kg/day (children, maximum 800 mg/day) in divided doses for 3 days
• Ivermectin (single dose): 12 mg or 150-200 μg/kg (adults), 150 μ/kg (children)
• Oral thiabendazole: 25 mg/kg twice daily for 3 days. Note that thiabendazole is no longer commercially available in Canada, United States and several other countries worldwide
• Topical 10 to 15% albendazole (or thiabendazole) solution or ointment (under occlusion) for localized lesions
• Oral antibiotics for secondary cellulitis

Cryotherapy (for solitary lesions): 1-2 cm ahead of the erythematous tract

Enhancing Healthcare Team Outcomes

The interprofessional healthcare team, including clinicians, pharmacists, and nurses should work together to help educate the public on strategies to avoid this disease in endemic areas as well as the importance of following treatment guidelines. While the clinician directs the course of treatment, dermatology nurses provide education, monitor patients, and educate patients and their families. Pharmacists review medications, check for drug-drug interactions, and provide patient and family education. WIth an interprofessional team approach, these cases can achieve better outcomes. [Level 5]

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