Hookworms (Ancylostoma duodenale and Necator americanus)

Authors: Authors: Hermann Feldmeier, M.D., Ph.D., Angela Schuster, M.D.

Authors (Second Edition, 2002): Reshad Dobardzic, M.D., Ph.D. , Peter J Hotez, M.D., Ph.D. , Azra Dobardzic, M.D., Ph.D.

Monograph
Tables
What's New
Reviews
History

PARISITOLOGY

Hookworm-related cutaneous larva migrans (HrCLM) is a parasitic skin disease caused by the migration of animal hookworm larvae in the epidermis. For decades, the terms creeping eruption and cutaneous larva migrans have been used interchangeably. In 2004, Caumes et al. (10) correctly pointed out that cutaneous larva migrans is a syndrome while creeping eruption is a clinical sign. The latter is defined as a linear or serpiginous, slightly elevated, erythematous track that moves forward in the skin in an irregular pattern. This clinical sign can be provoked by different parasites, such as animal hookworm larvae, other nematode larvae,Gnathostoma spp,Loa loa,Sarcoptes scabiei(scabies mites), or larvae of parasitic flies (migratory myiasis). In countries of the global South as well as in travelers returning from an endemic area, hookworm-related cutaneous larva migrans is the most common cause of a creeping eruption.

Biology, Transmission and Risk Factors

Adult hookworms live in the intestine of dogs and cats. Eggs are shed in faeces and hatch in the superficial layer of the soil within one day. They develop into infective third-stage larvae after about one week (2). Under favorable environmental conditions, larvae can survive and remain infectious for several months. After having located a host, larvae creep across the skin and probe sites suitable for penetration into the epidermis (25). How rapidly a larva can penetrate the stratum corneum of the epidermis remains unknown.

Usually,hookworm-related cutaneous larva migransis caused by hookworm larvae from dogs and cats (Ankylostoma caninum, A. braziliensis, Uncinaria stenocephala). Other nematodes of domestic and wild animals may also causehookworm-related cutaneous larva migrans.

Transmission occurs when naked skin comes into contact with contaminated soil. Walking barefoot is probably the most common type of exposure. Depending on local clothing habits and age-specific behavior, other areas of the skin may be exposed (31). Rarely, exposure takes place indoors. In Kuala Lumpur, a native visitor became infected when he took showers in a bathroom, soiled with cat excreta (40). In Serbia, a man developed multiple lesions on his back after having repaired his car in a garage laying below a car and wearing only shorts (49).

Exceptionally, larvae may be transmitted through fomites. For instance, if washed clothes are dried on the ground, larvae may creep on the textile from surrounding soil, resulting in infection when the piece of clothing is worn. In Naples, Italy, a small epidemic occurred in customers who had bought dry flowers, bark and spikes to prepare floral arrangements (22). Apparently, the material had been soiled by cat excreta when deposited in a humid shed.

In a study in rural Brazil young age, male sex, living in a house without a solid floor, always walking barefoot on the soil and the presence of animal faeces on the compound were identified as independent risk factors (28). Wearing protective footwear - e.g. sandals on the way to the beach and on the beach - may reduce the risk of infection (50).

In warm-climate countries, there is a distinct seasonal variation of hookworm-related cutaneous larva migrans, with a peak incidence during the rainy season. The risk of infestation is up to 15 fold higher in the rainy season as compared to the dry season (29).

Epidemiology and Disease Occurrence

Hookworm-related cutaneous larva migransis endemic in many resource-poor communities in the global South (19,24,28,29,35,42,43). A study in an impoverished community in Manaus, Brazil, showed a prevalence of 9.4% (F. Reichert, unpublished observation 2010). In rural communities in Northeast Brazil the prevalence in the general population was up to 4% and up to 15% in children (28,29,31). A high prevalence ofhookworm-related cutaneous larva migransin the human population reflects the presence of many dogs and cats in the community infected with hookworms, which are not, or not regularly, treated with antihelmintics (23).

In high-income countries with temperate climate,hookworm-related cutaneous larva migransoccurs sporadically or in the form of small epidemics. Epidemic cases are usually associated with atypical climatic conditions, such as prolonged periods of warm weather and rainfall. Cases have been reported in Germany, France, Great Britain, New Zealand, and USA (from New Jersey down to Texas) (1,7,12,16,18,26,34,37,48,61).

Travelers account for the great majority of cases ofhookworm-related cutaneous larva migransseen by health-care professionals in high-income countries (5,6,8,14,27,30,32). A study of 30 GeoSentinel sites in > 17.000 travelers who consulted a travel clinic found a prevalence of 2–3% (20). In descending order of frequency, the infection had been acquired in the Caribbean, Southeast Asia, Central America and South America.

With the high number of refugees and migrants from endemic areas during the last years and regular traveling home to countries of origin of settled immigrants the number of imported cases ofhookworm-related cutaneous larva migransis expected to rise significantly in Europe and the US.

Clinical Manifestations

Usually, the pruritus begins shortly after a larva has penetrated into the epidermis. Sandground observed itching within 1 hour after penetration of a singleA.brazilienselarva, whereas the creeping eruption became visible only after a few days (42). By contrast, in experimental infection withU.stenocephala, itchy papules developed after 4–6 days, and a track appeared after 2 weeks (21). In two French boys who were simultaneously infected during holidays at a beach in Northeast Brazil, the incubation period varied considerably being 15 days in one child and 165 days in the other (47). This indicates that host factors significantly influence the incubation period and likely also the natural history of disease.

The first sign is a small reddish papule, indicating the penetration site. Thereafter, the characteristic serpiginous, slightly elevated, erythematous track becomes visible. Itching becomes increasingly intense and is described as very uncomfortable by the patient (28,31). A study in an endemic area showed that 81% patients reported sleep disturbances due to the intense itching (31). Over time, lesions tend to become superinfected with pathogenic bacteria as a result of scratching (31). Vesiculo - bullous lesions are not rare (54). Bullae may reach several centimetres in diameter.

Folliculitis is a less common manifestation ofhookworm-related cutaneous larva migrans. Hitherto, it has only been described in travelers returning from tropical countries (11,36,55). During holidays at a beach in Thailand, a Dutch traveler developed folliculitis with a dozen of small papules of ± 3mm in diameter, which changed color from bluish to red and became increasingly itchy (52). The lesions were localized mainly in the pubic region, trunk and breasts. No tracks were seen between the papules. The pathophysiological basis of this particular presentation remains unclear. It was suggested that multiple larvae penetrate simultaneously and become trapped in follicular canals. However, van Nispen tot Pannerden did not find evidence for trapped hookworm larvae in a skin biopsy(52).

Fever in travelers withhookworm-related cutaneous larva migransmay indicate a yet undiagnosed HIV infection (56). Multifocal perigenital lesions may mimic vulvo-vaginitis (3).

The intense inflammation around the track is triggered by a complex immune response. In patients living in an endemic area in Brazil, interleukin (IL)-4, IL-5, IL-6 and I-10 were significantly elevated (46).

Depending on the hookworm species, the larval track may advance a few millimeter to a centimeter per day (31). The systematic measurements of track lengths in patients with a known point of exposure demonstrated that the mean distance of migration of the larva was 2.7 mm per day (31). Using this figure, it is possible to infer the time of exposure, and hence the location, where the infection took place.

Hookworm-related cutaneous larva migranssignificantly impairs the quality of life in individuals living in an endemic area (44).

Diagnosis

The diagnosis of hookworm-related cutaneous larva migrans is essentially clinical. It is supported by a recent travel history, and the possibility of exposure. The characteristic serpiginous track is pathognomonic. Systematic biopsies in a series of 38 patients failed to demonstrate a larva in all but one case (H. Feldmeier and A. Schuster, unpublished observation 2011). However, all sections showed a particular histological pattern with a marked eosinophilia in the epidermis, the dermis and the hypodermis. Eosinophilia may or may not be present. In a study in Germany, 20% of returning travelers withhookworm-related cutaneous larva migrans, presented eosinophilia, however, the infection status regarding other helminths was not known (32). Epiluminescence microscopy may help to visualize a migrating larva (59).

The differential diagnosis includes scabies, loiasis, myiasis, cercarial dermatitis (schistosomiasis), urticaria, tinea corporis, psoriasis and contact dermatitis. Hookworm-related cutaneous larva migranscan also mimic herpes zoster (36). However, the latter follows the anatomic path of a peripheral nerve and does not progress in the unpredictable manner a larvae track progresses. Hookworm-related cutaneous larva migransfolliculitis is difficult to differentiate from papular-nodular lesions caused by other nematode species (41).

Although the diagnosis ofhookworm-related cutaneous larva migransis straight forward, frequently patients have to consult several physicians until the correct diagnosis is made (33,40,49,52).

Laboratory Diagnosis

In travelers, eosinophilia is the only remarkable finding in the blood. However, the sign is neither constant nor specific. There is not immunological test.

Pathogenesis

Since animal hookworm larvae cannot penetrate the basal membrane of human skin, they remain confined to the epidermis. In this compartment, they are unable to develop further and to complete their lifecycle, as they would do in an appropriate animal host. As human beings are a dead end for the parasite,hookworm-related cutaneous larva migransgenerally is a self-limiting disease. However, if not treated properly, the disease persists for months causing significant morbidity (5,8,39).

SUSCEPTIBILITY IN VITRO AND IN VIVO

No data exists.

Special Situations

Not applicable.

Immunosuppressed Hosts

In endemic areas it is not uncommon that HIV infection andhookworm-related cutaneous larva migranscoexist (17,60), however, there is no evidence that HIV infection makes patients more susceptible tohookworm-related cutaneous larva migrans.

Antiparasitic Treatment

Principally, as larvae eventually die in situ and remains of the parasites are eliminated by tissue repair mechanisms over time,hookworm-related cutaneous larva migransis a self-limited disease. However, even a single lesion should be treated correctly. Hookworm-related cutaneous larva migranscauses intense pruritus for weeks to months, lesions are frequently superinfected and the conditions impairs the patient's quality of life.

Topical Treatment

For decades topical thiabendazole was the standard treatment. The cream has to be applied twice daily for 5-7 days. In two studies the efficacy was about 98% (13,32).

In many countries, Thiabendazole cream is not available as a commercial preparation. It has to be formulated by crushing 500 mg tablets into a water soluble cream base at a concentration of 15%.

The complicated dosage reduces the compliance. Therefore, the topical application of thiabendazole is only recommended if neither ivermectin nor Albendazole are at hand.

Oral treatment

Ivermectin is the drug of choice. A single dose (200 μg per kg bodyweight) kills the migrating larvae effectively (8) If the first treatment fails, a second dose usually provides a definitive cure (9,51). A single dose of ivermectin is more effective than a single dose of albendazole (8,9).

Vanhaecke et al. (53) have shown that the efficacy of ivermectin varies depending on the clinical presentation. Whereas 98% of patients presenting only a creeping dermatitis were cured after a single dose of ivermectin, 34% of patients with hookworm-associated folliculitis needed several doses. This confirms previous findings (55).

Oral albendazole (400 mg daily, given for 5–7 days) cured 92–100%, of the patients (58).

Oral therapy with thiabendazole for 5 days was effective in one patient with AIDS and an advanced level of immunosuppression (17). In a study of 67 Belgian patients the only failure after treatment with oral ivermectin was observed in an immunedeficient patient. Whether immunocompromised patients need a different dosage is not known.

Oral albendazole is contraindicated in children < 6 years and ivermectin in children < 5 years. However, a study from Mexico showed that ivermectin is safe in children aged from 14 months on (15). Due to frequent and severe adverse events, oral thiabendazole should be prescribed with caution (4).

Adjunctive Therapy

Pruritus can be treated symptomatically with antihistamines. Bacterial superinfection should be treated locally with an appropriate antibiotic. The tetanus immune status has to be checked.

Procedures not recommended

Freezing the track with liquid nitrogen is both ineffective and painful and should be avoided since the visible end of the track does not reflect the true location of the larvae (30). In one study, none of seven patients treated with liquid nitrogen was cured (14). In another study cryotherapy with liquid nitrogen was unsuccessful in six patients and resulted in severe blistering or ulceration (32).

ENDPOINTS FOR MONITORING THERAPY

Cessation of pruritus and regression of local inflammation indicate that the larva has died (45). Within four weeks the immunological alterations normalize (46).

VACCINES

There are no vaccines available.

PREVENTION

No studies exist.

REFERENCES

1.Beattie PE, Fleming CJ. Cutaneous larva migrans in the west coast of Scotland. Clin Exp Dermatol 2002;27:248-249. [PubMed]

2.Beaver PC. Larva migrans. Exp Parasitol 1956;5:587-621. [PubMed]

3.Benardon S, Ramoni S, Boneschi V, Cusini M, Veraldi S. Multifocal perigenital cutaneous larva migrans. Giornale Italiano Di Dermatologia E Venereologia 2014;149:477-478. [PubMed]

4.Bisoffi Z, Buonfrate D, Angheben A, Boscolo M, Anselmi M, Marocco S, Monteiro G, Gobbo M, Bisoffi G, Gobbi F. Randomized clinical trial on ivermectin versus thiabendazole for the treatment of strongyloidiasis. PLoS Negl. Trop. Dis. 2011;5:e1254. [PubMed]

5.Blackwell V, Vega-Lopez F. Cutaneous larva migrans: clinical features and management of 44 cases presenting in the returning traveller. Br. J. Dermatol. 2001;145:434-437. [PubMed]

6.Bouchaud O, Houze S, Schiemann R, Durand R, Ralaimazava P, Ruggeri C, Coulaud JP. Cutaneous larva migrans in travelers: a prospective study, with assessment of therapy with ivermectin. Clin Infect Dis 2000;31:493-498. [PubMed]

7.Bradley J. Home-grown cutaneous larva migrans. N Z Med J 1999;112:241-242. [PubMed]

8.Caumes E, Carriere J, Guermonprez G, Bricaire F, Danis M, Gentilini M. Dermatoses associated with travel to tropical countries: a prospective study of the diagnosis and management of 269 patients presenting to a tropical disease unit. Clin Infect Dis 1995;20:542-548. [PubMed]

9.Caumes E. Treatment of cutaneous larva migrans and Toxocara infection. Fundam clin pharmacol 2003;17:213-216. [PubMed]

10.Caumes E, Danis M. From creeping eruption to hookworm-related cutaneous larva migrans. Lancet Infect Dis 2004;4:659-660. [PubMed]

11.Caumes E, Ly F, Bricaire F. Cutaneous larva migrans with folliculitis: report of seven cases and review of literature. Br. J Dermatol 2002;146:314-316. [PubMed]

12.Conde JF, Feldman SR, Vallejos QM, Quandt SA, Whalley LE, Brooks T, Cabral G, Fleischer AB, Arcury TA.Cutaneous larva migrans in a migrant Latino Farmworker. J Agromedicine 2007;12:45. [PubMed]

13. Davis CM, Israel RM.Treatment of creeping eruption with topical thiabendazole. Arch Dermatol 1968;97:325-236 [PubMed]

14.Davies HD, Sakuls P, Keystone JS. Creeping eruption. A review of clinical presentation and management of 60 cases presenting to a tropical disease unit. Arch Dermatol 1993;129: 588-591. [PubMed]

15.del Mar Saez-De-Ocariz M, McKinster CD, Orozco-Covarrubias L, Tamayo-Sanchez L, Ruiz-Maldonado R. Treatment of 18 children with scabies or cutaneous larva migrans using ivermectin. Clinical and Experimental Dermatology 2002;27:264-267. [PubMed]

16.Diba VC, Whitty CJ, Green T. Cutaneous larva migrans acquired in Britain. Clin Exp Dermatol 2004;29:555-556. [PubMed]

17.Edwards SK, Carne CA. Larva migrans as a cause of fever in an HIV-positive man. Int J STD AIDS 1998;9:54-55. [PubMed]

18.Esser AC, Kantor I, Sapadin AN. Souvenir from the Hamptons - a case of cutaneous larva migrans of six months' duration. The Mount Sinai J Med 1999;66:334-335. [PubMed]

19.Feldmeier H, Schuster A. Hookworm-related cutaneous larva migrans. European J Clin Microbiol Infect Dis 2012;31:915-918.

20.Freedman DO, Weld LH, Kozarsky PE, Fisk T, Robins R, Von Sonnenburg F, Keystone JS, Pandey P, Cetron MS, GeoSentinel Surveillance Network. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med 2006;354:119-130. [PubMed]

21.Fülleborn F. Experimentally generated "creeping eruption". Dermatol Wochenschr 1926;83:1474-1475.

22.Galanti B, Fusco FM, Nardiello S. Outbreak of cutaneous larva migrans in Naples, Southern Italy. Trans R Soc Trop Med Hyg. 2002;96:491-492. [PubMed]

23.Guimarães AM, Alves EG, de Rezende GF, Rodrigues MC.Toxocarasp eggs andAncylostomasp larva in public parks, Brazil. Rev Saude Publica 2005;39:293-295. [PubMed]

24. Gutierrez de la Solana Dumas J, Alvarez MM, Manzur KJ. An outbreak of cutaneous larva migrans.Rev Cubana Med Trop 1983;35:303-316. [PubMed]

25.Haas W, Haberl B, Syafruddin Idris I, Kallert D, Kersten S, Stiegeler P.Behavioural strategies used by the hookwormsNecator americanusandAncylostoma duodenaleto find, recognize and invade the human host. Parasitol Res 2005;95:39. [PubMed]

26.Herrmann A, Christoph T, Sebastian G. Larva migrans "saxoniae": larva migrans infection in Saxony. J Dtsch Dermatol Ges. 2004;2:46-48. [PubMed]

27.Heukelbach J, Gomide M, Araújp F, Pinto NSR, Santana RD, Brito JRM, Feldmeier H. Cutaneous larva migrans and tungiasis in international travelers exiting Brazil: an airport survey. J Travel Med 2007;14:374-380. [PubMed]

28. Heukelbach J, Wilcke T, Feldmeier H.Cutaneous larva migrans (creeping eruption) in an urban slum in Brazil.Int. J. Dermatol. 2004;43:511-515. [PubMed]

29. Heukelbach J, Wilcke T, Meier A, Saboia Moura RC, Feldmeier H.A longitudinal study on cutaneous larva migrans in an impoverished Brazilian township. Travel Med Infect Dis 2003;1:213-218. [PubMed]

30.Hochedez P, Caumes E. Hookworm-related cutaneous larva migrans. J Travel Med 2007;14:326-333. [PubMed]

31.Jackson A, Calheiros CML, Soares VL, Harms G, Feldmeier H. A study in a community in Brazil in which cutaneous larva migrans is endemic. Clin. Infect. Dis. 2006;43:13-18. [PubMed]

32.Jelinek T, Maiwald M, Nothdurft HD, Loscher T. Cutaneous larva migrans in travelers: synopsis of histories, symptoms, and treatment of 98 patients.Clin Infect Dis 1994;19:1062-1066. [PubMed]

33. Kitchen M, Wilhelm M, Moser-Oberthaler S, Höpfl R, Ratzinger G, Van Ahn N, Schmuth M. Das kutane Larva migrans Syndrom: Schwierigkeiten bei Diagnose und Behandlung anhand von drei Fallbeispielen. Wiener Klinische Wochenschrift 2014;126:46-50. [PubMed]

34.Klose C, Mravak S, Geb M, Bienzle U, Meyer CG. Autochthonous cutaneous larva migrans in Germany. Trop Med Int Hlth. 1996;1:503-504. [PubMed]

35.Lee CP, Bishop LJ. The incidence of cutaneous larva migrans in Montserrat, Leeward Islands, West Indies. West Indian Med J 1988;37:22-24. [PubMed]

36.Malvy D, Ezzedine K, Pistone T, Receveur MC, Longy-Boursier M. Extensive cutaneous larva migrans with folliculitis mimicking multimetameric herpes zoster presentation in an adult traveler returning from Thailand.J Travel Med 2006;13:244-247. [PubMed]

37. Müller-Stöver I, Richter J, Häussinger D. In Deutschland erworbene Larva migrans cutanea. Dtsch. Med Wochenschr. 2010;135:859-861. [PubMed]

38.Pichard DC, Hensley J.R, Williams E, Apolo A.B, Klion AD, DiGiovanna JJ. Rapid development of migratory, linear, and serpiginous lesions in association with immunosuppression. J Am Acad Dermatol 2014;70:1130-1134. [PubMed]

39.Richey TK, Gentry RH, Fitzpatrick JE, Morgan AM. Persistent cutaneous larva migrans due toAncylostomaspecies. South Med J 1996;89:609-611. [PubMed]

40.Robson NZ, Othman S. A case of cutaneous larva migrans acquired from soiled toilet floors in urban Kuala Lumpur. Med J Malaysia 2008;63:331-332. [PubMed]

41.Sakai H, Otsubo S, Nakao M, Yamasaki H, Kagei N, Iizuka H. Multiple papules and nodules on the face and neck caused by the larvae of an unknown nematode: A noncreeping type eruption. J Am Acad Dermatol 2008;58:668-670. [PubMed]

42.Sandground JH. Creeping eruption in the Netherland East Indies caused by the invasion of the larvae ofAncylostoma braziliense. Geneesk Tijdschr Ned Indië 1939;13:805-810.

43.Santarém VA, Giuffrida R, Zanin GA. Cutaneous larva migrans: reports of pediatric cases and contamination byAncylostomaspp larvae in public parks in Taciba, Sao Paulo State.Rev Soc Bras Med Trop 2004;37:179-181. [PubMed]

44. Schuster A, Lesshaft H, Reichert F, Ignatius H, Feldmeier H.Life quality impairment caused by hookwork- related cutaneous larva migrans (HrCLM) in resource-poor communities in Manaus, Brazil. PloS Neglected Tropical Diseases 2011;5:e1355. [PubMed]

45.Schuster A, Lesshaft H, Reichert F, Talhari S, Guedes de Oliveira S, Ignatius H, Feldmeier H. Hookworm-related cutaneous larva migrans in northern Brazil: resolution of clinical pathology after a single dose of ivermectin. Clin Infect Dis 2013;57:1155-1157. [PubMed]

46.Shimogawara-Furushima R, Hata N, Schuster A, Lesshafft H, Guedes de Oliveira S, Akao N, Ohta N, Ignatius H, Feldmeier H. Hookworm-related cutaneous larva migrans in patients living in an endemic community in North Brazil: immunological patterns before and after ivermectin treatment. European J Microbiol Immunol 2013;3:358-366. [PubMed]

47. Siriez J, Angoulvant F, Buffet P, Cleophax C, Bourrat E. Individual variability of the cutaneous larva migrans incubation period. Pediatr Dermatol 2010;27:211-212. [PubMed]

48.Stevens MS, Geduld J, Libman M, Ward BJ, McCarthy AE, Vincelette J, Ghesquiere W, Hajek J, Kuhn S, Freedman D, Kain KC, Boggild AK. Dermatoses among returned Canadian travelers and immigrants: surveillance report based on CanTravNet data, 2009-2012. CMAJ open 2015;3:e119-e126. [PubMed]

49.Tomovic D, Skiljevic D, Zivanovic D, Tanasilovic S, Dakovic Z, Vukicevic J, Pavlovic MD, Medenica L. Two cases of probable endogenous extensive cutaneous larva migrans in Serbia. Acta Dermatoven APA 2008;17:37-40. [PubMed]

50.Tremblay A, MacLean JD, Gyorkos T, Macpherson DW. Outbreak of cutaneous larva migrans in a group of travellers.Trop. Med. Int. Hlth. 2000;5:330-334. [PubMed]

51. Van den Enden E, Stevens A, Van Gompel A. Treatment of cutaneous larva migrans. N Engl J Med 1998;339:1246-1247. [PubMed]

52. van Nispen tot Pannerden C, van Gompel F, Rijinders BJ, Caumes E, den Hollander JG. An itchy holiday. Netherlands J Med 2007;65:188-190. [PubMed]

53. Vanhaecke C, Perigon A, Monsel G, Regnier S, Bricaire F, Caumes E. The efficacy of single dose ivermectin in the treatment of hookworm related cutaneous larva migrans varies depending on the clinical presentation. J Europ Acad Dermatol Venereol2014;28:655-657. [PubMed]

54.Veraldi S, Arancio L. Giant bullous cutaneous larva migrans. Clin Exp Dermatol 2006;31:613-614. [PubMed]

55.Veraldi S, Bottini S, Carrera C, Gianotti R. Cutaneous larva migrans with folliculitis: a new clinical presentation of this infestation. J Eur Acad Dermatol Venereol. 2005;19:628-630. [PubMed]

56.Veraldi S, Persico MC. HIV, cutaneous larva migrans and fever. Int J STD AIDS 2007;18:433-434. [PubMed]

57. Sanguigni S, Marangi M, Teggi A, De Rosa F. Albendazole in the therapy of cutaneous larva migrans. Transact Roy Soc Trop Med Health 1990;84:831. [PubMed]

58.Veraldi S, Rizzitelli G. Effectiveness of a new therapeutic regimen with albendazole in cutaneous larva migrans. Europ J Dermatol 1999;9:352-353. [PubMed]

59.Veraldi S, Schianchi R, Carrera C. Epiluminescence microscopy in cutaneous larva migrans. Acta Derm Veneorol 2000;80:233. [PubMed]

60.Zein U, Habib H. An HIV positive man with single erythema skin lesion: a case report of neglected tropical disease. Acta Med. Indones. 2013;45:220-223. [PubMed]

61.Zimmermann R, Combemale P, Piens MA, Dupin M, Le Coz C. Cutaneous larva migrans, autochthonous in France. Apropos of a case. Annales de dermatologie et de vénéréologie 1995;122:711-714. [PubMed]