eMedicine Specialties > Pediatrics: General Medicine > Parasitology
Cutaneous Larva Migrans: Treatment & Medication
Updated: Jan 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Treatment of cutaneous larva migrans (CLM) is anthelminthics, with pruritus resolving within 24-72 hours and serpiginous tracts resolving within 7-10 days.
- Antihistamines and topical corticosteroids can be used in conjunction with anthelminthics for symptomatic relief of pruritus.
- Oral antibiotics are used if secondary impetiginization or cellulitis is present.
Surgical Care
- Prior to the availability of anthelminthics, treatment by cryosurgery with liquid nitrogen, ethyl chloride spray, or carbon dioxide slush was effective in 60-70% of individuals with CLM.
- Cryosurgery is painful and often requires multiple treatments. Cryosurgery at the leading edge of the track was imprecise because the migrating larvae are usually located several centimeters beyond this point.
Consultations
- Consultation with a dermatologist, infectious diseases specialist, or both may be appropriate.
Medication
Anthelmintics
Anthelmintics are the drug of choice for cutaneous larva migrans (CLM). Parasite biochemical pathways are different from the human host; thus, toxicity is directed to the parasite, egg, or larvae. Mechanism of action varies within the drug class. Antiparasitic actions may include the following:
- Inhibition of microtubules causes irreversible block of glucose uptake
- Tubulin polymerization inhibition
- Depolarizing neuromuscular blockade
- Cholinesterase inhibition
- Increased cell membrane permeability, resulting in intracellular calcium loss
- Vacuolization of the schistosome tegument
- Increased cell membrane permeability to chloride ions via chloride channels alteration
Ivermectin (Stromectol)
Broad-spectrum anthelmintic that is not FDA approved for the treatment of CLM but is suggested as DOC by many studies. Single-dose therapy makes this drug convenient. Available in the United States because of FDA approval for treatment of onchocerciasis and strongyloidiasis. Selectively binds with glutamate-gated chloride ion channels in invertebrate nerve and muscle cells, causing cell death. Half-life is 16 h; metabolized in liver. Available in 3 mg tabs.
Adult
0.2 mg/kg PO as a single dose
Typical weight-based doses (administer PO once as a single dose)
46-60 kg: 12 mg
61-75 kg: 15 mg
76-90 kg: 18 mg
91-105 kg: 21 mg
106-120 kg: 24 mg
Pediatric
Administer PO once as a single dose
<15 kg: 3 mg
16-30 kg: 6 mg
31-45 kg: 9 mg
May interact with other ligand-gated chloride channels (eg, those gated by GABA)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Treat mothers who intend to breastfeed only when risk of delayed treatment outweighs possible risks to newborn caused by ivermectin excretion in milk; may cause nausea, vomiting, mild CNS depression, and drowsiness
Albendazole (Albenza)
Broad-spectrum antihelminthic drug used in nematode and cestode infestations; not FDA approved for treatment of CLM but has been shown by many studies to be highly effective with no or minimal adverse effects. Available in the United States because of FDA approval for treatment of hydatid disease and neurocysticercosis. Decreases ATP production in worm, causing energy depletion, immobilization, and, finally, death.
Adult
400 mg/d PO for 3 d
Pediatric
10-15 mg/kg PO qd for 3-5 d; not to exceed adult dose
Coadministration with carbamazepine may decrease efficacy; dexamethasone, cimetidine, and praziquantel may increase toxicity
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue use if LFT levels significantly increase (resume when levels decrease to pretest values); adverse effects include fever, abdominal pain, and transitory alopecia
Thiabendazole (Mintezol)
Standard treatment of CLM has been topical thiabendazole; however, high rate of relapse is noted. Also, with less common causes due to human nematodes, does not prevent development of systemic illness or eliminate intestinal reservoir. PO thiabendazole is only FDA-approved drug for treatment of CLM. Therapy with PO formulation has been fraught with adverse effects.
Adult
Topical: (use 500 mg/5 mL PO susp or 10% extemporaneously prepared solution)
Apply topically to tracks and 2 cm beyond leading edge qid; continue 1-2 d after tracks resolve or saturate gauze with the PO susp and apply to tracks and 2 cm beyond leading edge, then cover area where applied with plastic wrap overnight for 3 consecutive nights
Oral (chewable tab or PO susp):
<70 kg: 25 mg/kg PO q12h pc for 2-5 d; not to exceed 3 g/d
>70 kg: 1.5 g PO q12h pc for 2-5 d
Chew tabs thoroughly before swallowing; take after meals with fruit juice
Pediatric
Administer as in adults
May elevate serum levels of theophylline, increasing toxicity (monitor serum levels and reduce dose prn)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Closely monitor in patients with hepatic or renal dysfunction; may cause nausea, vomiting, and mild CNS depression; topical administration may cause stinging, burning, erythema, and edema in excoriated areas; tab should be chewed before swallowing
Mebendazole (Vermox)
Causes worm death by selectively and irreversibly blocking uptake of glucose and other nutrients in susceptible adult intestine where helminths dwell.
Adult
100 mg PO bid for 3 d; second course if patient not cured in 3-4 wk
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Carbamazepine and phenytoin may decrease effects of mebendazole; cimetidine may increase mebendazole levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Adjust dose in hepatic impairment
More on Cutaneous Larva Migrans |
| Overview: Cutaneous Larva Migrans |
| Differential Diagnoses & Workup: Cutaneous Larva Migrans |
 Treatment & Medication: Cutaneous Larva Migrans |
| Follow-up: Cutaneous Larva Migrans |
| Multimedia: Cutaneous Larva Migrans |
| References |
| Further Reading |
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Keywords
cutaneous larva migrans, CLM, Ancylostoma braziliense, Ancylostoma caninum, Ancylostoma ceylanicum, Ancylostoma duodenale, Ancylostoma tubaeforme, Bunostomum phlebotomum, Capillaria, creeping eruption, diarrhea, duck hunter itch, Gnathostoma, ground itch, hookworm, hypersensitivity reaction, malabsorption, Necator americanus, nematodes, ocular larva migrans, plumber itch, roundworm, sandworm disease, serpiginous pruritic lesions, Strongyloides myopotami, Strongyloides papillosus, Strongyloides stercoralis, Strongyloides westeri, Uncinaria stenocephala
