Patient history often involves travel to endemic areas and a history of walking barefoot. The most common initial finding is a small reddish papule that progresses to a serpiginous pruritic rash with a slow rate of progression from less than 1 to 2 cm per day. The initial presentation may vary depending on species. Disease from A. braziliense manifests within 1 hour, while papular lesions may take days to appear when U. stenocephala is the organism that infects a person. Vesiculobullous disease may occur as well, and papulopustular inflammation of the follicles has been documented, although this is not common.[2][6][7]

Diagnosis is usually made clinically based on the history of recent travel to endemic areas in combination with a classic serpiginous rash. The rash is very pruritic, raised, and has a slower rate of millimeters up to 2 cm per day. This distinguishes it from other migrating infections. Blood tests are not necessary for diagnosis. Not only is eosinophilia found in less than 40% of patients with CLM, but it is also not specific. Non-invasive optical coherence tomography has been used to establish the diagnosis, although this is not often used. Skin biopsy is occasionally performed and may reveal the nematode larvae within a circular canal. A biopsy is not sensitive, and while secondary changes and infiltrate assist in diagnosis, it is not necessary to confirm this clinical diagnosis.[2][5]

The disease is self-limited; however, if the infection is local, topical thiabendazole 10% solution or 15% ointment may be tried first. The cream is applied 2 to 3 times daily for 5 to 10 days. Small studies have shown improvement of pruritus may occur as early as 48 hours after beginning treatment, and cure rates as high as 98% within ten days have been achieved. The largest advantage of topical therapy is a lack of systemic absorption and side effects. Still, the use is limited by multiple applications daily, and utility is less valuable with multiple lesions.

Local disease has historically been treated with cryotherapy. However, freezing the leading edge of the skin with either liquid nitrogen, solid carbon dioxide, or ethylene chloride spray has been shown to be largely ineffective and should be avoided.

For multiple lesions or severe infestation, albendazole and ivermectin are first-line systemic therapies. Oral albendazole, 400 mg daily for 3 to 5 days, is very effective with cure rates nearing 100%. Some studies show that a 7-day course of albendazole may decrease the rates of recurrent disease. Oral ivermectin is also effective, and its advantage is a patient only has to take a one-time dose of 12 mg by mouth. Cure rates near 100% with ivermectin administration.

Mebendazole is another antihelminthic agent; however, it has poor bioavailability, absorption, and, subsequently, poor efficacy and should not be used as a first-line medication. Also ineffective include topical steroids, oral steroids, and antibiotics. While systemic corticosteroids may reduce itching, the side-effect profile limits usefulness.

In addition to pharmacologic therapy, banning dogs from beaches may decrease the deposition of larvae into the soil. Notably, towels do not consistently protect against transmission, but wearing protective footwear can be effective. [3][4][6][7][8]

While the creeping eruption and clinical signs lead to a diagnosis in most cases, other organisms may be confused about this infective processes. Scabies, loiasis, myiasis, schistosomiasis, tinea corporis, and contact dermatitis may have some overlapping features. These are all easily differentiated by a lack of serpentine migration. The most similar disease is the migrating lesion of Strongyloides stercoralis, termed larva currens. This progressing serpiginous infection is differentiated by its rate of progression with intermittent movement and rates of several centimeters by the hour. Additionally, the pattern is haphazard, and disease more often occurs on the perianal skin, thighs, or the trunk. A human trematode, Fasciola gigantica, causes a disease called fascioliasis and is also in the differential. Non-infectious linear or serpiginous dermatoses include jellyfish stings, lichenoid eruptions, and phytophotodermatitis, which again are non-migratory. Creeping ingrown hair may present but is rare. [2][4][6]

The disease is often self-limited, and resolution without treatment is the rule rather than the exception. However, migration may continue for months, and during this time, pruritus may be severe, often interfering with sleep. Treatment, topical or systemic results in cure rates near 100%, and although recurrence can occur, it is also well prevented and responsive to systemic therapy.[3][6][7]

Complications include secondary infection, most commonly with Staphylococcus aureus and Streptococcal species. Secondary impetiginization occurs in up to 8% of cases. If the infection is prolonged post-streptococcal glomerulonephritis has been reported. Although it is well accepted that larvae cannot penetrate the basement membrane of skin, visceral disease has been rarely reported. Larvae have been identified in sputum, found in viscera of a human host, and also found in skeletal musculature. Host response to infection has rarely occurred as erythema multiforme. [9]

The interprofessional healthcare team, including clinicians, pharmacists, and nurses should work together to help educate the public on strategies to avoid this disease in endemic areas as well as the importance of following treatment guidelines. While the clinician directs the course of treatment, dermatology nurses provide education, monitor patients, and educate patients and their families. Pharmacists review medications, check for drug-drug interactions, and provide patient and family education. WIth an interprofessional team approach, these cases can achieve better outcomes. [Level 5]