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Download Article PHOTO QUIZ Serpiginous Lesion on the Foot Joy Tao, Eden Pappo Lake ABSTRACT: This is a case of an erythematous, serpiginous, DISCUSSION pruritic eruption located on the dorsal left foot of a patient This patient has a serpiginous eruption suggestive of who recently traveled to Jamaica. The patient is other- hookworm-related cutaneous larva migrans (CLM) that wise healthy. A multiple-choice question is presented, was likely acquired during his trip to Jamaica. Hookworm- and readers will be challenged to identify an appropriate related CLM is most frequently caused by Ancylostoma treatment option based on case presentation, symptoms, braziliense and Ancylostoma caninum, which are cat and and patient history. An answer is given followed by a dog hookworm larvae, respectively, that can penetrate discussion of disease transmission, diagnosis, clinical fea- the skin (Chris & Keystone, 2016). The hookworm tures, and appropriate management of the lesion. larvae are generally confined to the epidermis, as they are unable to penetrate the basement membrane. Therefore, PATIENT HISTORY humans are incidental hosts in which the larvae are unable A 24-year-old White man presents to a clinic with an to complete their life cycle. It is common in developing erythematous, serpiginous, slightly raised rash on his left nations in the Caribbean, Central and South America, and foot that has been present for 1 week (Figure 1). The lesion Southeast Asia. Travelers often contract CLM after walking is mildly pruritic but not painful. The patient has used Neosporin on the area with no response. Two months ago, the patient visited Jamaica, and he is concerned it might be an infection. He is not diabetic and denies any injuries to the area or any similar symptoms in the past. The remainder of his physical examination is noncontributory. Multiple-Choice Question Which of the following is the most appropriate treat- ment option for this patient? A. Topical triamcinolone acetonide B. Topical tacrolimus C. Oral prednisone D. Oral ivermectin E. Oral diphenhydramine Answer D. Oral ivermectin Joy Tao, BS, Stritch School of Medicine, Loyola University Chicago, Maywood, IL. Eden Pappo Lake, MD, Division of Dermatology, Department of Medicine, Loyola University Chicago, Maywood, IL. The authors declare no conflict of interest. Correspondence concerning this article should be addressed to Joy Tao, BS, 2160 S. 1st Ave., Maywood, IL 60153. E-mail: [email protected] Copyright B 2018 by the Dermatology Nurses’ Association. FIGURE 1. Serpiginous, erythematous tract on the left dorsal DOI: 10.1097/JDN.0000000000000435 foot. VOLUME 10 | NUMBER 6 | NOVEMBER/DECEMBER 2018 297 Copyright © 2018 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited. PHOTO QUIZ barefoot or sitting on contaminated beaches or soil in CLM is usually self-limiting and resolves spontaneously tropical countries. As a result, the lesions most commonly without treatment within 2Y8 weeks. However, patients occur on the feet, buttocks, and legs (Heukelbach & often prefer active intervention, especially because lesions Feldmeier, 2008). can be severely pruritic and can affect patients’ quality of The diagnosis of CLM is based on clinical symptoms life (Prickett & Ferringer, 2015). In addition, treatment and recent travel history. Biopsies are typically not performed can decrease the risk of superimposed bacterial infection because the larvae are usually found 1Y2 centimeters away secondary to excoriation (Kincaid, Klowak, Klowak, & from the visible border (Prickett & Ferringer, 2015). Boggild, 2015). One dose of oral ivermectin (200 2g/kg) Patients have one to three lesions on average, and the and 3 days of oral albendazole (400Y800 mg) are both incubation period is usually less than 1 week after exposure. effective treatments. Patients with numerous lesions or However, larvae have been reported to be dormant for folliculitis may require additional doses of anthelmintic as long as 7 months. A characteristic symptom of CLM is agents (Monsel & Caumes, 2008). If those medications creeping eruption also termed ‘‘creeping dermatitis,’’ are unavailable or contraindicated, topical 10% albendazole which is a serpiginous or linear cutaneous tract that migrates ointment applied twice a day for at least 10 days is a viable in an irregular pattern. The eruptions are approximately substitute (Hochedez & Caumes, 2008). Topical 10%Y15% 3 millimeters wide, slightly raised, and erythematous thiabendazole ointment applied three times daily for a (Figure 1) as well as pruritic and sometimes painful. Lesions minimum of 15 days is also utilized to treat CLM, but it may also be vesiculobullous or edematous or present as requires strict patient compliance (Caumes, 2000). folliculitis or diffuse urticarial papules (Heukelbach & Feldmeier, 2008; Hochedez & Caumes, 2008; Prickett & Ferringer, 2015). REFERENCES Creeping eruptions may also be present in other parasitic Caumes, E. (2000). Treatment of cutaneous larva migrans. Clinical Infectious Y cutaneous diseases including larva currens, dracunculiasis, Diseases, 30(5), 811 814. Chris, R. B., & Keystone, J. S. (2016). Prolonged incubation period of scabies, and loiasis. Larva currens is caused by Strongyloides hookworm-related cutaneous larva migrans. Journal of Travel Medicine, stercoralis and is similar in presentation. Strongyloides 23(2), tav021. Elston, D. M., Czarnik, K., Brockett, R., & Keeling, J. H. (2003). What’s stercoralis is found in the southern United States, Southeast eating you? Strongyloides stercoralis. Cutis, 71(1), 22Y24. Asia, Central Africa, and South America. It can be distin- Heukelbach, J., & Feldmeier, H. (2008). Epidemiological and clinical guished from CLM by the speed of progression in the characteristics of hookworm-related cutaneous larva migrans. The Lancet Infectious Diseases, 8(5), 302Y309. epidermis. Whereas CLM progresses only a few millimeters Hochedez, P., & Caumes, E. (2008). Common skin infections in travelers. to a centimeter a day, larva currens is much more rapid Journal of Travel Medicine, 15(4), 252Y262. and can migrate up to 10 centimeters per hour (Elston, Kincaid, L., Klowak, M., Klowak, S., & Boggild, A. K. (2015). Management of imported cutaneous larva migrans: A case series and mini-review. Czarnik, Brockett, & Keeling, 2003; Monsel & Caumes, Travel Medicine and Infectious Disease, 13(5), 382Y387. 2008). In addition, rashes caused by larva currens only Monsel, G., & Caumes, E. (2008). Recent developments in dermatological persist for a few hours and characteristically occur on the syndromes in returning travelers. Current Opinion in Infectious Diseases, 21(5), 495Y499. trunk and thighs and near the anus (Heukelbach & Prickett, K. A., & Ferringer, T. C. (2015). What’s eating you? Cutaneous Feldmeier, 2008). larva migrans. Cutis, 95(3), 126Y128. 298 Journal of the Dermatology Nurses’ Association Copyright © 2018 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited..
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