Creeping Eruption on the Move: A Case Series from Northern India.

Cutaneous larva migrans (CLM) is the most common tropically acquired dermatosis caused by infection with hookworm larvae. It is commonly seen in tropical areas, and in people who have a history of foreign travel and of walking barefoot on sandy soil or beaches. An increased incidence has been seen in non-endemic areas due to change in environmental and behavioral factors. The presence of this entity is questionable in Northern region as the environmental conditions and the type of soil is not favorable, both of which are required for the survival of nematode. We describe a case series of six patients presented during winter season in the outpatient department of Dermatology within a short period of 2 months. We also review the clinical features of various other creeping eruptions and factors that are responsible for boosting infection in North India.

What was known?

Cutaneous larva migrans (CLM) is a distinctive self-limiting epidermal parasitic skin disease (EPSD) that results from skin penetration by the larval form of nematodes.

Introduction

Creeping eruption is a classical presentation of accidental human exposure to infective nematode.[1] It presents with the characteristic serpiginous erythematous slightly elevated track associated with severe pruritus.[1] The diagnosis is made on the basis of the history and classical clinical presentation. Here we report a case series of six patients presented in the outpatient department of Dermatology within a short span of 2 months.

Case Reports

Case 1

A 5-year-old male child was referred from pediatric department for the evaluation of erythematous pruritic cutaneous lesions. These lesions were present since 2 weeks. Mother gave history of child playing in muddy soil. Cutaneous examination revealed single slightly elevated erythematous, curvilinear, track of 0.2 × 10 cm size over the forehead [Figure 1].

Figure 1

Single erythematous, curvilinear, track over the forehead

Case 2

A 4-year-old female child presented with an itchy skin lesion over nape and both cheeks since 1 month. She was treated with topical and systemic antifungals and antihistamines with no response. Examination revealed single curvilinear tract encircling the neck and sides of bilateral cheeks of size 0.1 × 16 cm [Figure 2].

Figure 2

Single curvilinear track encircling the neck and sides of bilateral cheeks

Case 3

A 21-year-old male presented with a single creepy lesion over dorsum of the right hand since 1 week. On examination, there was a single curved lesion on the middle finger of the right hand of size varying from 0.2 × 2 cm [Figure 3].

Figure 3

Single curved lesion present over dorsum of the right hand

Case 4

A 25-year-old male football player presented with a single intensely itchy eruption on right thigh. On examination, a single serpentine lesion of size 0.2 × 5 cm present on the medial side of the right thigh [Figure 4].

Figure 4

Single serpentine lesion present on the medial side of the right thigh

Case 5

A 50-year-old farmer presented with a single itchy serpiginous Lesion over left foot for the last 3 weeks. The patient had a history of walking bare foot in the fields. Cutaneous examination showed an erythematous curvilinear lesion of 0.2 × 6-8 cm2 on dorsum of the left foot associated with scattered eczematous papules and excoriations [Figure 5].

Figure 5

An erythematous curvilinear lesion on dorsum of left foot with scattered eczematous papules and excoriations

Case 6

A 30-year-old female presented with multiple creepy, itchy lesions Over the abdomen from last 1 week. On examination, there were multiple disseminated lesions present on the abdomen of size varying from 0.1 × 1-3cm [Figure 6].

Figure 6

Multiple disseminated serpiginous tracks on the abdomen

None of our patients had history of travelling to endemic areas. All hematological and biochemical investigations were within normal limits. Chest X-ray and absolute eosinophil counts were normal. Tablet albendazole 400 mg/day was given to all the patients for three consecutive days, following which all lesions resolved completely. No recurrence was seen in any case on follow up.

Discussion

Creeping eruption is a cutaneous sign defined as a cutaneous migratory linear trail. It was first described by Lee in 1874; later in 1893 Croker gave the term “Cutaneous larvae migrans” (CLM).[2] It is the most common tropically acquired dermatosis.[3] Hookworm (Ancylostoma braziliense and Ancylostoma caninum) is the most common cause of CLM followed by Gnathostoma spp., Loa loa, sarcoptes scabiei and larvae of parasitic flies.[4] The Different etiologies of creeping eruption can be distinguished according to the travel history, the characteristics of cutaneous eruption and the associated clinical signs (Discussed in Table 1).[5] The epidemiological data on CLM varies in the literature although it has an increased incidence in tropical and subtropical countries which includes Caribbean islands, Africa, South America, South East Asia and South eastern United States.[6]

Table 1

Creeping eruptions and their characteristic features

Eggs of the nematode usually (Ancylostoma braziliense) are found most commonly in dog and cat feces. The eggs are passed through the stool onto warm sandy soil, which serves as a rich incubator and requires a temperature of 23-30°C.[7] The eggs subsequently mature into filariform larvae which penetrate the skin of new human host. Thus, the incidence of the disease is mainly dependent on environmental factors and behavioral factors.[8] Environmental factor includes warm and rainy season with damp sandy soil whereas behavioral factors are walking bare foot and lack of basic sanitation.[8] It is more common among children and young males in rainy season. It can be explained by gender-related behavioral patterns like males walking bare foot in fields or children playing in sandy soil.

Characteristic clinical picture of CLM is so distinctive that the skin biopsy and laboratory investigation are not generally required. The invasive procedure like skin biopsy rarely identifies the parasites, since the anterior end of the track does not necessarily indicate the location of larva.[2] Recently, epiluminescence microscopy has been used to visualize larva but the sensitivity is not known.[2] Complications of CLM are infective and allergic. Infective includes superadded infection with Staphylococcus aureus or Streptococcus pyogenes due to eczematization. Rarely it may present with vesicobullous lesion, folliculitis and allergic pulmonary response (presents as Loffler's syndrome).[2]

In Indian scenario, the disease commonly occurs in the coastal areas of the country where the suitable condition exists.[7] This entity is considered quite rare in Northern India as the environmental conditions are not suitable i.e. the type of soil and extremes of temperature. A sporadic case, however, has been reported from Himachal Pradesh. Presentation of six patients during winter season is quite interesting as the temperature during winters in Northern region is not optimum for the nematode. The probable factor for the occurrence of this entity in the non-endemic region may be due to the increased level of hookworm infection in stray animals. Also, the behavioral factor i.e. walking bare foot predisposes the condition. Thus, we need further studies on the incidence of CLM in order to know the other factors which are responsible for the occurrence of CLM in the North Indian region.

All patients were treated with albendazole and showed complete clearance of lesions. However, a single dose of ivermectin (200 μg/kg) and 3 day regimen of albendazole (400 mg/day) has a similar efficacy of 92-100%.[2] Oral thiabendazole, the first drug used in CLM is poorly tolerated and associated with gastrointestinal complains i.e. nausea, vomiting etc. Topical thiabendazole is also available with fewer side effects.[2] Cutaneous larva migrans can be prevented by treating the dogs and cats regularly with anthelmintic drugs at community level and at individual level by protecting the skin from coming in contact with the contaminated soil.

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..