Creeping Eruptions- Causes, Symptoms, Diagnosis, and Treatment

Introduction:

Humans become an unplanned dead-end host because the traveling parasite dies, and its skin manifestations usually resolve within months, caused by several different parasites. The lesions, called creeping eruptions, are characteristically red, raised and fluid-filled, linear or serpentine (like a snake), and intensely itchy. Activities that pose a risk include contact with contaminated sand or soil. Furthermore, carpenters, electricians, plumbers, farmers, ranchers, gardeners, pest exterminators, groundskeepers, and laborers are at an increased risk of getting cutaneous larva migrans.

How Are Creeping Eruptions Otherwise Known?

Cutaneous larva migrans (CLM), creeping eruptions, creeping verminous dermatitis, sandworm eruptions, plumer itch, and duck hunter's itch are all terms that describe a clinical finding caused by several different parasites.

What Causes Creeping Eruption?

Organisms that cause creeping eruptions are the different variants of hookworms and parasites.

Although many parasites may cause CLM, the most common infective agents are:

1. Ancylostoma Braziliense - A hookworm that invades wild domestic dogs and cats.

2. Ancylostoma Caninum - An Australian dog hookworm.

Other causative agents are:

1. Uncinaria stenocephala (European dog hookworm).

2. Bunostomum phlebotomum (cattle hookworm).

3. Strongyloides papillosus (sheep, goat, and cattle parasite).

4. Ancylostoma ceylonicum, Ancylostoma tubaeforme (cat hookworm).

5. Strongyloides westeri (parasite of horses).

What Happens in Animal Hosts?

Humans become accidental hosts when they come into contact animal defecation-contaminated soil. Adult hookworms release eggs while in the dog's and cat's intestines. The eggs pass from the stool onto warm sandy soil in a rich incubator. The eggs eat the soil bacteria and mature into non-infectious larvae and subsequently into infectious larvae after two months, gaining the ability to penetrate the skin of a new host.

What Happens in a Human Host?

Hookworm larvae can enter through broken skin or hair follicles. After contact, the infectious larvae penetrate the intact outer skin through an enzyme - proteases. The larvae lack the enzyme collagenase (it helps penetrate the basement membrane and invade the inner skin). Therefore, the larvae are blocked in the outer skin but can still move around with the help of hyaluronidase. After entering the outer skin, the larvae wander through the skin. The time from penetration into the human host to the onset of symptoms can vary between two to 50 days.

The movement of hookworm larvae causes a distinct lesion in the form of a highly itchy, linear, serpiginous eruption. The larvae settle one to two centimeters ahead of the lesion region, so local invasive treatment focusing on the tract is often ineffective.

What Are the Signs and Symptoms?

Signs and symptoms of creeping eruption can either be localized or systemic.

Local signs and symptoms include:

• Extreme itch.

• Tingling or prickling sensation.

• Red, raised and vesicular, and linear or serpentine.

• Single or multiple lesions; may sometimes be painful.

• Extends every day.

• As the larvae move ahead and to centimeters change the tracts, fluid accumulates in the passage. These blisters become thick and encrusted.

• Serpentine inflammatory tracts may be visible on the surface of the skin.

• The most frequently affected areas are approximately three mm in width; 15 to 20 cm in length. The larvae advance from a few millimeters by infectious larvae are the foot, spaces between the toes, finger, and buttocks in young children because the larvae have been shown to penetrate thin clothing such as bathing suits. Less frequently affected areas include the hand and breasts.

• Skin picking and red sore over the lesion are usually seen.

Systemic signs and symptoms of creeping eruptions are:

• Wheezing, dry cough, and urticaria.

• Acute abdominal pain, anorexia, nausea, and diarrhea may be present when GIT is involved.

• When the airway is involved, asthma, pulmonary infiltrates, eosinophilia, fever, polymorphous erythema, and skin eruption may be present.

What Is the Test to Diagnose Creeping Eruption?

Creeping eruption is diagnosed based on clinical findings and known epidemiologic exposure.

• History of complete travel, beach visit, being near uncovered sandboxes, or working in an occupation favorable to exposure.

• A complete blood count shows transient peripheral eosinophilia.

• Total serum immunoglobulins test shows increased IgE levels.

• Skin biopsy shows larval burrows and their tracts. Skin biopsy usually does not detect larvae as it moves rapidly.

What Diseases Appear Similar to Creeping Eruptions?

Creeping eruption resembles,

1. Contact dermatitis.

2. Bacterial or fungal infections.

3. Scabies.

4. Lichen planus.

5. Myiasis.

6. Loiasis or other migratory parasites.

What Is the Treatment of Creeping Eruption?

Before the 1960s, topical modalities such as ethyl chloride spray, carbon dioxide snow, liquid nitrogen, piperazine citrate, Gaudin, phenol, electrocautery, and X-ray therapy were used. But these approaches failed, as they did not kill the larvae.

Chemotherapy - Chloroquine, Antimony, and Diethylcarbamazine were attempted, but no satisfactory results.

Anti-parasitic drugs - Thiabendazole, Ivermectin, Mebendazole, Albendazole, Pyrantel pamoate.

Insecticide - Permethrin.

When left untreated, the creeping eruption is self-limiting and will disappear in weeks or months.

What Is the Prognosis of Creeping Eruption?

As a creeping eruption is self-limiting, it has an excellent prognosis.

What Are the Complications of Creeping Eruptions?

Sometimes creeping eruptions can last up to two years.

Possible complications of creeping eruptions include:

1. Cellulitis.

2. Eosinophilic enterocolitis (spread of the infection to the small intestine).

3. Loffler syndrome (spread of the infection to the lungs).

4. Bacterial skin infections are triggered by scratching.

How Can Creeping Eruptions Be Prevented?

• Proper public hygiene and deworming of dogs and cats can decrease hookworm infection.

• Wear shoes when moving out because hookworm infection can occur when there is direct contact of skin with the infected larvae.

Conclusion:

A creeping eruption is a zoonotic infestation caused by the penetration and passage of infected larvae from dogs and cats into the outer skin of a human. Patient education is essential for preventing creeping eruptions. Knowledge of the life cycle of animal hookworms, clinical signs and symptoms, and complete travel history is vital to start early treatment. Patients are advised to avoid walking barefoot when visiting humid places. Pet owners, pet breeders, and pet groomers should be guarded.