Approach

CLM is typically self-limiting and eventually resolves completely without sequelae even if no specific treatment is used (usually within 2-8 weeks). However, giving an anthelmintic medication results in rapid resolution of symptoms, usually within 1 week, and reduces the risk of bacterial superinfection.[2]​ Pruritus and extension of the creeping eruption often resolve within 48 hours of therapy; the rash disappears more slowly.[30]

Oral anthelmintics

The treatment of choice is a single dose of oral ivermectin, which is usually curative.[22][30]​ Response rates are poorer in cases of CLM-associated folliculitis and repeated courses may be required.[46] Adverse effects are rare, although local bullous reactions have been reported. Ivermectin is not approved by the US Food and Drug Administration for the treatment of CLM so patients should be counselled about off-label use.[2] It should be avoided in children weighing <15 kg, due to limited clinical experience.

Oral albendazole is an acceptable alternative to ivermectin, although single-dose treatment results in lower cure rates.[30][47][48][49]​​ Cure rates for 3 to 5 days of treatment match those of ivermectin, ranging from 77% to 100%.​[4][22]​​​[50] Adverse effects are minimal and mostly consist of mild nausea, vomiting, and headache. Albendazole should be avoided in children <1 year of age, owing to limited clinical experience.

Oral tiabendazole was available in the past for treating CLM but has now been discontinued in some countries.[3]​​[4]​ While tiabendazole was effective in treating CLM, the much higher incidence of adverse effects (mostly gastrointestinal) associated with its use resulted in ivermectin and albendazole being the preferred treatment choices.[51]

Data on the use of ivermectin and albendazole in pregnancy are lacking, although for both drugs, animal studies have shown evidence of teratogenicity. Therefore, treatment should either be delayed until after pregnancy (if symptoms have not yet resolved spontaneously) or supervised by a tropical medicine specialist.

If there is no response to initial treatment after 1 to 2 weeks (no reduction in pruritus or the creeping eruption), treatment can be repeated using the same drug and dose.[30] In a small minority of cases, a third course of treatment may be required (e.g., if folliculitis present).[5] However, if symptoms and signs have not resolved after 2 courses of treatment, referral to a tropical-medicine specialist and/or investigation of alternative diagnoses should be considered.

Symptoms and skin findings may recur after an initial positive response to treatment, probably because the hookworm larvae were damaged but not completely killed. Relapse usually occurs within weeks of the initial presentation and responds in most cases to a repeated course of treatment.[3][22]​​​[30]

Treatment not recommended

Cryotherapy with liquid nitrogen should be avoided. Because the larva is usually located several centimetres ahead of the advancing end of the creeping eruption, freezing the track will be ineffective. Larvae have also been shown to survive freezing. Furthermore, cryotherapy is invasive, painful, and may result in significant formation of bullae that can ulcerate.​[4]

Given the rapid response to anthelmintic therapy, neither topical corticosteroids nor antihistamines are recommended treatments for CLM. In addition, it does not appear as though the pruritus is histamine related.

Use of this content is subject to our disclaimer