Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

non-pregnant adults and children

1st line – oral anthelmintic

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ACUTE
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non-pregnant adults and children
1st line – 

oral anthelmintic

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]

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] 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, owing 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 and range from 77% to 100%.[4][22]​​​​[50] Albendazole should be avoided in children <1 year of age owing to limited clinical experience.

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.

Primary options

ivermectin: children ≥15 kg and adults: 200 micrograms/kg orally as a single dose

Secondary options

albendazole: children 1-2 years old: 200 mg orally once daily for 3 days; children ≥2 years old and adults: 400 mg orally once daily for 3 days

pregnant

1st line – delay oral anthelmintic until after pregnancy or consult tropical medicine specialist

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ACUTE
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pregnant
1st line – 

delay oral anthelmintic until after pregnancy or consult tropical medicine specialist

Data on 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 be supervised by a tropical medicine specialist.

ONGOING

no response to initial treatment or relapse

1st line – repeat oral anthelmintic

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ONGOING
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no response to initial treatment or relapse
1st line – 

repeat oral anthelmintic

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]

Primary options

ivermectin: children ≥15 kg and adults: 200 micrograms/kg orally as a single dose

Secondary options

albendazole: children 1-2 years old: 200 mg orally once daily for 3 days; children ≥2 years old and adults: 400 mg orally once daily for 3 days

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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