Medication

Medication Summary

See Table 1, below.

Table 1. Medication Summary (Open Table in a new window)

Medication Name	Dosage/Application	Contraindications	Availability	Notes
Dimethicone ^{[59, 60, 61]}	Apply directly to the affected area once or twice daily. If legion numbers are under 40 or legions are in clusters: Apply 3 drops of NYDA® (approximately 50 μL each) to the exposed posterior side of the flea. Repeat the procedure 3x over 10 minutes. If fleas are in excessive hyper-keratotic skin and located on top of each other: NDYA® must be used to wet the skin intensely and repeatedly.	No known contraindications. Shown to be safe for extended use.	Available under the brand name NYDA®. But not available in all tungiasis endemic areas.
Topical Antibiotic Lotions ^{[64, 58, 61]}	0.8% ivermectin, 0.2% metrifonate and 5% thiabendazole lotions, applied 2 consecutive days.	No contraindications reported.	All are readily available except for metrifonate, which is no longer commercially available.
Zanzarin ^{[63, 8]}	Apply to all infected areas and areas at risk for tungiasis infection twice daily.	No known contraindications.	No longer commercially available, but made of ingredients that could be locally manufactured in areas where tungiasis is common.
Neem Seed Oil and Coconut Oil ^{[61, 69]}	One drop (approximately 0.05 ml) of a mixture of 20% cold-pressed virgin neem seed oil and 80% virgin coconut oil applied to the embedded flea’s abdominal tip on days 1 and 3.	Actives in cold-pressed neem oil are not toxic following oral, inhalation, or dermal exposure.	May be locally available where both neem trees and coconut palms grow.	The mixture requires proper storage as azadirachtin has a high sensitivity to ultraviolet light, pH, and temperature.

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Thielecke M, Raharimanga V, Rogier C, Stauss-Grabo M, Richard V, Feldmeier H. Prevention of tungiasis and tungiasis-associated morbidity using the plant-based repellent Zanzarin: a randomized, controlled field study in rural Madagascar. PLoS Negl Trop Dis. 2013. 7 (9):e2426. [QxMD MEDLINE Link].
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Obebe OO, Aluko OO. Epidemiology of tungiasis in sub-saharan Africa: a systematic review and meta-analysis. Pathog Glob Health. 2020 Oct. 114 (7):360-369. [QxMD MEDLINE Link].
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Mashek H, Licznerski B, Pincus S. Tungiasis in New York. Int J Dermatol. 1997 Apr. 36(4):276-8. [QxMD MEDLINE Link].
Poppiti R Jr, Kambour M, Robinson MJ, Rywlin AM. Tunga penetrans in south Florida. South Med J. 1983 Dec. 76(12):1558-60. [QxMD MEDLINE Link].
Brothers W, Heckmann R. Tungiasis (Tunga penetrans) in Utah. J Parasitol. 1979 Oct. 65(5):782. [QxMD MEDLINE Link].
Hager J, Jacobs A, Orengo IF, Rosen T. Tungiasis in the United States: a travel souvenir. Dermatol Online J. 2008 Dec 15. 14(12):3. [QxMD MEDLINE Link].
GIDEON Infectious Diseases - Tungiasis. Date Accessed: 5/5/2011. [Full Text].
Nte AR, Eke FU. Jigger infestation in children in a rural area of Rivers State of Nigeria. West Afr J Med. 1995 Jan-Mar. 14(1):56-8. [QxMD MEDLINE Link].
Arene FO. The prevalence of sand flea (Tunga penetrans) among primary and post-primary school pupils in Choba area of the Niger Delta. Public Health. 1984 Sep. 98(5):282-3. [QxMD MEDLINE Link].
Ade-Serrano MA, Ejezie GC. Prevalence of tungiasis in Oto-Ijanikin village, Badagry, Lagos State, Nigeria. Ann Trop Med Parasitol. 1981 Aug. 75(4):471-2. [QxMD MEDLINE Link].
de Carvalho RW, de Almeida AB, Barbosa-Silva SC, Amorim M, Ribeiro PC, Serra-Freire NM. The patterns of tungiasis in Araruama township, state of Rio de Janeiro, Brazil. Mem Inst Oswaldo Cruz. 2003 Jan. 98(1):31-6. [QxMD MEDLINE Link].
Ugbomoiko US, Ofoezie IE, Heukelbach J. Tungiasis: high prevalence, parasite load, and morbidity in a rural community in Lagos State, Nigeria. Int J Dermatol. 2007 May. 46(5):475-81. [QxMD MEDLINE Link].
Feldmeier H, Witt L, Schwalfenberg S, Linardi PM, Ribeiro RA, Capaz RA, et al. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil. VI. Natural history of the infestation in laboratory-raised Wistar rats. Parasitol Res. 2007 Dec. 102(1):1-13. [QxMD MEDLINE Link].
Heukelbach J, Franck S, Feldmeier H. High attack rate of Tunga penetrans (Linnaeus 1758) infestation in an impoverished Brazilian community. Trans R Soc Trop Med Hyg. 2004 Jul. 98(7):431-4. [QxMD MEDLINE Link].
Kehr JD, Heukelbach J, Mehlhorn H, Feldmeier H. Morbidity assessment in sand flea disease (tungiasis). Parasitol Res. 2007 Jan. 100(2):413-21. [QxMD MEDLINE Link].
Kibaki L. Intensity the war on jiggers. Available at http://www.capitalfm.co.ke/eblog/2011/03/17. Accessed: June 20, 2013.
Olukya G. Jiggers-something rotten in Uganda. Available at http:www.timeslive.co.za/africa/article722622.ece. Accessed: June 20, 2013.
Deka MA. Mapping the Geographic Distribution of Tungiasis in Sub-Saharan Africa. Trop Med Infect Dis. 2020 Jul 24. 5 (3):[QxMD MEDLINE Link].
Mazigo HD, Bahemana E, Konje ET, Dyegura O, Mnyone LL, Kweka EJ, et al. Jigger flea infestation (tungiasis) in rural western Tanzania: high prevalence and severe morbidity. Trans R Soc Trop Med Hyg. 2012 Apr. 106(4):259-63. [QxMD MEDLINE Link].
Grupper M, Potasman I. Outbreak of tungiasis following a trip to Ethiopia. Travel Med Infect Dis. 2012 Sep. 10(5-6):220-3. [QxMD MEDLINE Link].
Ugbomoiko US, Ofoezie IE, Heukelbach J. Tungiasis: high prevalence, parasite load, and morbidity in a rural community in Lagos State, Nigeria. Int J Dermatol. 2007 May. 46(5):475-81. [QxMD MEDLINE Link].
Damazio OR, Silva MV. Tungiasis in schoolchildren in Criciúma, Santa Catarina State, South Brazil. Rev Inst Med Trop Sao Paulo. 2009 Mar-Apr. 51(2):103-8. [QxMD MEDLINE Link].
Joseph JK, Bazile J, Mutter J, Shin S, Ruddle A, Ivers L, et al. Tungiasis in rural Haiti: a community-based response. Trans R Soc Trop Med Hyg. 2006 Oct. 100(10):970-4. [QxMD MEDLINE Link].
Widmer CE, Azevedo FC. Tungiasis in a free-ranging jaguar (Panthera onca) population in Brazil. Parasitol Res. 2012 Mar. 110(3):1311-4. [QxMD MEDLINE Link].
Linardi PM, Calheiros CM, Campelo-Junior EB, Duarte EM, Heukelbach J, Feldmeier H. Occurrence of the off-host life stages of Tunga penetrans (Siphonaptera) in various environments in Brazil. Ann Trop Med Parasitol. 2010 Jun. 104(4):337-45. [QxMD MEDLINE Link].
Muehlen M, Feldmeier H, Wilcke T, Winter B, Heukelbach J. Identifying risk factors for tungiasis and heavy infestation in a resource-poor community in northeast Brazil. Trans R Soc Trop Med Hyg. 2006 Apr. 100(4):371-80. [QxMD MEDLINE Link].
Ugbomoiko US, Ariza L, Ofoezie IE, Heukelbach J. Risk factors for tungiasis in Nigeria: identification of targets for effective intervention. PLoS Negl Trop Dis. 2007 Dec 5. 1(3):e87. [QxMD MEDLINE Link]. [Full Text].
Lynne Elson 1,*, Katherine Wright 2, Jennifer Swift 2 and Herman Feldmeier 3. Control of Tungiasis in Absence of a Roadmap: Grassroots and Global Approaches. Tropical Medicine and Infectious Disease. 2017. 2:[Full Text].
Feldmeier H, Heukelbach J, Eisele M, Sousa AQ, Barbosa LM, Carvalho CB. Bacterial superinfection in human tungiasis. Trop Med Int Health. 2002 Jul. 7(7):559-64. [QxMD MEDLINE Link].
Joseph JK, Bazile J, Mutter J, Shin S, Ruddle A, Ivers L. Tungiasis in rural Haiti: a community-based response. Trans R Soc Trop Med Hyg. 2006 Oct. 100(10):970-4. [QxMD MEDLINE Link].
Rathe M, Rafn A, Poulsen T, Mohey R. [Tungiasis case after a trip to Kenya]. Ugeskr Laeger. 2009 Mar 2. 171(10):818. [QxMD MEDLINE Link].
Heukelbach J, Wilcke T, Eisele M, Feldmeier H. Ectopic localization of tungiasis. Am J Trop Med Hyg. 2002 Aug. 67(2):214-6. [QxMD MEDLINE Link].
Veraldi S, Schianchi R, Cremonesi R. Bullous tungiasis. Int J Dermatol. 2005 Dec. 44(12):1067-9. [QxMD MEDLINE Link].
Di Stefani A, Rudolph CM, Hofmann-Wellenhof R, Müllegger RR. An additional dermoscopic feature of tungiasis. Arch Dermatol. 2005 Aug. 141(8):1045-6. [QxMD MEDLINE Link].
Cabrera R, Daza F. Dermoscopy in the diagnosis of tungiasis. Br J Dermatol. 2009 May. 160(5):1136-7. [QxMD MEDLINE Link].
Bauer J, Forschner A, Garbe C, Röcken M. Dermoscopy of tungiasis. Arch Dermatol. 2004 Jun. 140(6):761-3. [QxMD MEDLINE Link].
Smith MD, Procop GW. Typical histologic features of Tunga penetrans in skin biopsies. Arch Pathol Lab Med. 2002 Jun. 126(6):714-6. [QxMD MEDLINE Link].
Eisele M, Heukelbach J, Van Marck E, Mehlhorn H, Meckes O, Franck S, et al. Investigations on the biology, epidemiology, pathology and control of Tunga penetrans in Brazil: I. Natural history of tungiasis in man. Parasitol Res. 2003 Jun. 90(2):87-99. [QxMD MEDLINE Link].
Thielecke M, Raharimanga V, Rogier C, Stauss-Grabo M, Richard V, Feldmeier H. Prevention of tungiasis and tungiasis-associated morbidity using the plant-based repellent Zanzarin: a randomized, controlled field study in rural Madagascar. PLoS Negl Trop Dis. 2013. 7 (9):e2426. [QxMD MEDLINE Link].
Heukelbach J. Revision on tungiasis: treatment options and prevention. Expert Rev Anti Infect Ther. 2006 Feb. 4 (1):151-7. [QxMD MEDLINE Link].
Thielecke M, Nordin P, Ngomi N, Feldmeier H. Treatment of Tungiasis with dimeticone: a proof-of-principle study in rural Kenya. PLoS Negl Trop Dis. 2014. 8 (7):e3058. [QxMD MEDLINE Link].
Miller H, Trujillo-Trujillo J, Mutebi F, Feldmeier H. Efficacy and safety of dimeticones in the treatment of epidermal parasitic skin diseases with special emphasis on tungiasis: an evidence-based critical review. Braz J Infect Dis. 2020 Mar-Apr. 24 (2):170-177. [QxMD MEDLINE Link].
Abrha S, Heukelbach J, Peterson GM, Christenson JK, Carroll S, Kosari S, et al. Clinical interventions for tungiasis (sand flea disease): a systematic review. Lancet Infect Dis. 2021 Aug. 21 (8):e234-e245. [QxMD MEDLINE Link].
Tardin Martins AC, de Brito AR, Kurizky PS, Gonçalves RG, Santana YRT, de Carvalho FCA, et al. The efficacy of topical, oral and surgical interventions for the treatment of tungiasis: A systematic review of the literature. PLoS Negl Trop Dis. 2021 Aug. 15 (8):e0009722. [QxMD MEDLINE Link].
Feldmeier H, Kehr JD, Heukelbach J. A plant-based repellent protects against Tunga penetrans infestation and sand flea disease. Acta Trop. 2006 Oct. 99(2-3):126-36. [QxMD MEDLINE Link].
Heukelbach J, Eisele M, Jackson A, Feldmeier H. Topical treatment of tungiasis: a randomized, controlled trial. Ann Trop Med Parasitol. 2003 Oct. 97(7):743-9. [QxMD MEDLINE Link].
Heukelbach J, Franck S, Feldmeier H. Therapy of tungiasis: a double-blinded randomized controlled trial with oral ivermectin. Mem Inst Oswaldo Cruz. 2004 Dec. 99(8):873-6. [QxMD MEDLINE Link].
Feldmeier H, Heukelbach J, Ugbomoiko US, Sentongo E, Mbabazi P, von Samson-Himmelstjerna G, et al. Tungiasis--a neglected disease with many challenges for global public health. PLoS Negl Trop Dis. 2014 Oct. 8 (10):e3133. [QxMD MEDLINE Link].
Buckendahl J, Heukelbach J, Ariza L, Kehr JD, Seidenschwang M, Feldmeier H. Control of tungiasis through intermittent application of a plant-based repellent: an intervention study in a resource-poor community in Brazil. PLoS Negl Trop Dis. 2010 Nov 9. 4(11):e879. [QxMD MEDLINE Link]. [Full Text].
Mutebi F, von Samson-Himmelstjerna G, Feldmeier H, Waiswa C, Bukeka Muhindo J, Krücken J. Successful Treatment of Severe Tungiasis in Pigs Using a Topical Aerosol Containing Chlorfenvinphos, Dichlorphos and Gentian Violet. PLoS Negl Trop Dis. 2016 Oct. 10 (10):e0005056. [QxMD MEDLINE Link].
Elson L, Randu K, Feldmeier H, Fillinger U. Efficacy of a mixture of neem seed oil (Azadirachta indica) and coconut oil (Cocos nucifera) for topical treatment of tungiasis. A randomized controlled, proof-of-principle study. PLoS Negl Trop Dis. 2019 Nov. 13 (11):e0007822. [QxMD MEDLINE Link].

Media Gallery

A. Tangential cut through a fully developed, gravid flea embedded in the stratum corneum of the epidermis. The flea's head and thorax are enfolded in the hypertrophic anterior abdominal segments. The epidermis is hyperplastic and shows papillomatosis, parakeratosis, and hyperkeratosis.B. Tangential cut through the posterior abdominal segments of an embedded sand flea. Next to the chitinous cuticle, a microabscess has formed.C. Dead parasite; the exoskeleton of the posterior abdominal segment has remained intact; the cuticle has disintegrated at the epidermal–dermal interface. The carcass is infiltrated by neutrophils, and pus has formed.D. The head of the flea is located at the epidermal–dermal interface, has penetrated the basal membrane, and is surrounded by many erythrocytes, presumably having leaked from a blood vessel. The abdomen of the parasite is separated from host tissue by a thick, chitinous cuticle.
A tungiasis lesion in substage 3a.
Scanning electron micrograph of flea on day 3 after penetration. The hypertrophic zone between abdominal segments 2 and 3 is gaining a bulging shape and looks like a life-belt (x100).
Scanning electron micrograph of flea on day 8 after penetration. The hypertrophy zone has taken the shape of a sphere. The 3 parts of abdominal segment 2 are completely bent apart. Together with the newly developed, crescent-shaped chitinous clasps, the anterior part of the flea looks like a 3-leafed clover (x32).
Scanning electron micrograph of flea 6 hours after beginning of penetration. The penetration is almost completed; only the last abdominal segments protrude through the skin (x240).
Scanning electron micrograph of flea in stage 2. The rear end, the genital opening, and the 4 pairs of stigmata form a miniature cone, which towers above the crater caused by pushing in abdominal segments 7 and 8 (x190).
Life cycle of Tunga penetrans - Fortaleza stages included. Compiled and designed by Fausto Bustos and Lucas Manfield.
Histopathologic findings in tungiasis.
Life cycle of the chigoe flea, Tunga penetrans. Courtesy of the CDC.
Complicated Tungiasis infection. Courtesy of Dermatology Atlas (http://www.atlasdermatologico.com.br/index.jsf) and Samuel Freire da Silva, MD.
Tungiasis lesion under toenail. Courtesy of Dermatology Atlas (http://www.atlasdermatologico.com.br/index.jsf) and Samuel Freire da Silva, MD.
Example of complicated infection with multiple tungiasis lesions and possible secondary infection. Courtesy of Wikimedia Commons [author R Schuster, https://commons.wikimedia.org/wiki/File:Jigger_infested_foot_(2).jpg].
Illustration of Tunga penetrans (sand flea) in its enlarged state. Courtesy of Wikimedia Commons [https://commons.wikimedia.org/wiki/File:ChiggerBMNH.jpg].
Removed parasite shown with needle. Courtesy of Wikimedia Commons [https://commons.wikimedia.org/wiki/File:Puce_chique_(Tonga_penetrans).jpg].
Tunga penetrans flea. Courtesy of Wikimedia Commons [author Philipp Weigell, https://commons.wikimedia.org/wiki/File:Tunga_penetrans_%281%29.JPG].
Image of Tungiasis infection on both feet. Courtesy of PLOS [Miller H, Ocampo J, Ayala A, Trujillo J, Feldmeier H. Very severe tungiasis in Amerindians in the Amazon lowland of Colombia: A case series. PLOS Neglected Tropical Diseases. 2019 Feb 7. Online at: https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0007068.].
Graphical abstract of predicted tungiasis occurrence within sub-Saharan Africa. Courtesy of MDPI [Deka MA. Mapping the Geographic Distribution of Tungiasis in Sub-Saharan Africa. Tropical Medicine and Infectious Disease. 2020 Jul 24;5(3):122. Online at: https://www.mdpi.com/2414-6366/5/3/122#.].

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Table 1. Medication Summary

Table 1. Medication Summary

Medication Name	Dosage/Application	Contraindications	Availability	Notes
Dimethicone ^{[59, 60, 61]}	Apply directly to the affected area once or twice daily. If legion numbers are under 40 or legions are in clusters: Apply 3 drops of NYDA® (approximately 50 μL each) to the exposed posterior side of the flea. Repeat the procedure 3x over 10 minutes. If fleas are in excessive hyper-keratotic skin and located on top of each other: NDYA® must be used to wet the skin intensely and repeatedly.	No known contraindications. Shown to be safe for extended use.	Available under the brand name NYDA®. But not available in all tungiasis endemic areas.
Topical Antibiotic Lotions ^{[64, 58, 61]}	0.8% ivermectin, 0.2% metrifonate and 5% thiabendazole lotions, applied 2 consecutive days.	No contraindications reported.	All are readily available except for metrifonate, which is no longer commercially available.
Zanzarin ^{[63, 8]}	Apply to all infected areas and areas at risk for tungiasis infection twice daily.	No known contraindications.	No longer commercially available, but made of ingredients that could be locally manufactured in areas where tungiasis is common.
Neem Seed Oil and Coconut Oil ^{[61, 69]}	One drop (approximately 0.05 ml) of a mixture of 20% cold-pressed virgin neem seed oil and 80% virgin coconut oil applied to the embedded flea’s abdominal tip on days 1 and 3.	Actives in cold-pressed neem oil are not toxic following oral, inhalation, or dermal exposure.	May be locally available where both neem trees and coconut palms grow.	The mixture requires proper storage as azadirachtin has a high sensitivity to ultraviolet light, pH, and temperature.

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Author

Darvin Scott Smith, MD, MSc, DTM&H, FIDSA Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Permanente Medical Group

Darvin Scott Smith, MD, MSc, DTM&H, FIDSA is a member of the following medical societies: American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Lisa Manzanete, BS MD Candidate, Loma Linda University School of Medicine

Disclosure: Nothing to disclose.

Lily Amaturo BS Candidate, Stanford University

Disclosure: Nothing to disclose.

Nadia Hemmat BA Candidate, Stanford University

Disclosure: Nothing to disclose.

Chief Editor

John L Brusch, MD, FACP Corresponding Faculty Member, Harvard Medical School

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Zachary S Wettstein Stanford University

Disclosure: Nothing to disclose.

Stephanie A Nevins Research Assistant, Department of Genetics, Snyder Lab, Stanford University School of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Neil F Gibbs, MD Voluntary Associate Professor, Departments of Pediatrics and Medicine, University of California, San Diego School of Medicine; Program Director, Pediatric Dermatologist, Department of Dermatology, Naval Medical Center, San Diego

Neil F Gibbs, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, and Society for Pediatric Dermatology