Definition

Cutaneous larva migrans (CLM), commonly referred to as creeping eruption, is a dermatological condition resulting from hookworm entering the body. Worms are categorized as parasitic microorganisms. CLM is predominantly prevalent in tropical regions. This cutaneous infection frequently arises in individuals residing in or having visited tropical nations.

Pinworm infections are the most common worm infections in underdeveloped countries, with CLM ranking as the second most prevalent. The prevalence is significantly higher in tropical regions characterized by warm climates, where individuals commonly engage in barefoot walking, particularly on beaches or living within socio-economically disadvantaged areas, hence increasing their exposure to animal feces.

Causes

CLM is attributed to various types of hookworm larvae. The larvae represent the immature stage of hookworm. Ancylostoma species are the hookworms most commonly responsible for CLM. Ancylostoma braziliense, a species of hookworm in domestic dogs and cats, is the primary cause of cutaneous larva migrans (CLM) across America and the Caribbean. In addition, dogs in Australia are commonly infected with Ancylostoma caninum, generally known as hookworm in dogs. Parasites inhabit and deposit eggs in the intestinal tract of domesticated animals, such as cats and dogs. The animal feces will deposit eggs of worms. Subsequently, the eggs would hatch and give rise to larvae, which could potentially cause infection.

Infection occurs when the larvae make contact with the skin and then penetrate the skin. Larvae are frequently discovered in contaminated soil or sand. The larvae infiltrate the skin to enter the body. Individuals who sit on the ground without protective materials, such as a towel, or wander barefoot, are more susceptible to hookworm larvae infection.

CLM is predominantly found in warm and humid climates, including the southeast United States, the Caribbean, Central and South America, Africa, the Middle East, and Southeast Asia. CLM is also frequently observed in areas with poor hygiene.

Risk factor

Several factors that increase the likelihood of developing CLM include:

1. Males

Compared to girls, boys are three times more likely to get CLM. This is believed to be because boys engage in more outdoor activities, they are more exposed to the ground when they play, and they are not supervised much by their parents.

2. Age range: 10-14 years

Children aged 10-14 have double the risk of experiencing CLM compared to younger kids. This is due to their increased engagement in activities outside of the home, greater exposure to outdoor environments, and reduced parental supervision.

3. Exposure to sand or soil

Individuals who choose to stroll without footwear are more susceptible to be infected by worm parasites compared to those who opt to wear even basic flip-flops. Children frequently engage in activities while they go barefoot, particularly during playtime. In addition, individuals who are employed in professions involving significant exposure to sand or soil, such as excavation or construction labor, may have an elevated risk.

4. Environment 

Several environmental factors can heighten the likelihood of acquiring CLM, such as:

• Outdoor surroundings
• Animal feces that are not cleaned up
• Unpaved roads
• Numerous wild creatures play and excrete waste on the road without supervision
• Poverty or low earnings

Symptoms

The manifestations of CLM typically become evident within the first five days following infection, however, occasionally the onset of symptoms may be delayed. Typical signs and symptoms include:

• Lesions or abnormal skin lesions are characterized by visible redness and curvy tracks on the skin. The skin lesions usually manifest as a crimson rash characterized by a snake-like pattern. This phenomenon is attributed to the movement of larvae beneath the skin. The lesion is capable of moving up to 2 centimeters within 24 hours.
• The lesions can cause discomfort and may be accompanied by sensations of itchiness, stinging, or pain
• Inflammation of the afflicted skin region

Cutaneous larva migrans can manifest on any body part, although it is most prevalent in regions that are prone to regular contact with soil or sand contaminated with parasites. These areas typically include the feet, buttocks, thighs, and hands.

Due to the pruritic nature of lesions, individuals with CLM often scratch the affected areas. Such actions can cause harm to the skin and heighten your risk of developing secondary bacterial infections. 

Diagnosis

CLM can be diagnosed by doctors by evaluating patient complaints, past activity or employment history, and the physical examination of skin lesions. If you reside in a humid or tropical region, providing your doctor with comprehensive details about your daily surroundings will assist the doctor in making an accurate diagnosis.

CLM is a self-limiting disease. The larvae residing beneath the skin often perish during a span of 5 to 6 weeks without treatment. Nevertheless, there are instances where the healing process may be prolonged.

Applying creams or ointments or taking oral medication helps speed up the healing process. The physician will prescribe antiparasitic medications to eradicate the infesting parasites. Antiparasitic medications commonly used in Indonesia are often given as oral medicines. In addition to prescribing medication, the doctor will also advise maintaining proper hygiene by showering twice a day with soap to keep your skin clean.

Management

CLM is a disease that can heal on its own. Larva under the skin usually dies within 5 to 6 weeks without treatment. However, in some cases, it may take longer to recover.

The use of cream drugs orphetamines or drinking drugs can help infection recover faster. Doctors will prescribe antiparasitic drugs to kill infected worms. Antiparasitic drugs circulating in Indonesia are generally in the form of drinking drugs. In addition to taking drugs, doctors will also recommend keeping the skin clean by bathing twice a day using soap.

Complications

Possible complications arising from CLM include:

• Itchiness can disrupt a patient's everyday activities
• Cellulitis or widespread infection of the skin and tissue under the skin can be caused by secondary bacterial infections, typically by Staphylococcus aureus and Streptococcus pyogenes bacteria. Kidney inflammation resulting from streptococcal infections has also been observed in cases of persistent bacterial infections
• Worm-induced allergic responses
• On rare occasions, there have been reports of Loeffler's syndrome, which is characterized by the accumulation of eosinophils (a type of white blood cell) in the lungs as a result of parasite infections 

Prevention

If you are visiting a region where CLM is prevalent, there are various measures you can take to reduce the risk of contracting the infection:

• To minimize the chances of coming into contact with dirt or sand that may be contaminated with worm larvae, it is advisable to wear shoes or footwear
• It is advised to wear clothes that fully cover your thighs and buttocks. These parts of the body are particularly susceptible to CLM infections, as they can come into contact with parasites when sitting or lying down
• Refrain from sitting or sleeping in locations that may be contaminated, as doing so can raise your risk of your skin coming into contact with larvae
• Use a towel or cloth to cover soil surfaces that may be contaminated before sitting or sleeping on it
• Whenever feasible, steer clear of locations that are commonly visited by a multitude of animals, particularly dogs and cats. If you are need to travel to these regions, it is advisable to put on footwear
• Take into account the specific time and season when embarking on a trip, particularly when traveling abroad, the rainy season leads to a significant increase of CLM in various regions
• Certain developing countries use prophylactic treatment for those with a high susceptibility to infection, including:
• Pregnant women
• Children
• Occupations involving frequent contact with sand, soil, or a higher likelihood of encountering hookworms

When to see a doctor?

If you or your child develops a skin rash with a distinct shape and has symptoms of CLM infection as indicated above, it is advisable to seek medical advice promptly to prevent the condition from spreading and affecting daily activities.

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