Ivermectin vs. Albendazole for Cutaneous Larva Migrans

case report

A classic textbook case of cutaneous larva migrans (CLM) presented to our office two weeks ago. A 57-year-old woman had just returned from a one-week vacation in Jamaica, where she and her husband spent lots of time walking on the beach. Within two to three days of arriving in Jamaica, she developed increasingly itchy feet, which eventually precluded sleep. By the time she arrived back in the United States, her feet were red, hot, and markedly swollen. She was diagnosed with dermatitis and given a steroid injection, and within 24 hours had evidence of at least 30-40 serpiginous tracts on each foot, which quickly extended to the ankles.

She was seen in a local urgent care center and prescribed orally administered thiabendazole, which resulted in intractable nausea and vomiting for two days. In desperation, with progression of her creeping eruption, and unable to keep the medication down, she contacted our office and was given albendazole for five days. Remarkably, her husband showed no initial signs of infection, but within two days noticed involvement of two toes on the right foot, and was also given albendazole for five days. Both husband and wife rapidly responded without evidence of relapse at one month.

Comment by Carol A. Kemper, MD

CLM is caused by any number of skin-penetrating roundworm larvae but are usually caused by dog or cat hookworms (Ancylostoma). Within days of infection, an often markedly pruritic dermatitis develops, followed by the appearance of serpiginous tracts revealing the nematodes aimless wandering. Three-fourths of the infections occur on the lower extremities, while 12% occur on the buttocks and anogenital area and 7% on the upper extremities.1

Various therapeutic approaches have been used for this condition, including cryotherapy, topical administration of thiabendazole, and systemic administration of thiabendazole, albendazole, and ivermectin. Cryotherapy is often destructive and ineffective, especially in cases of more severe infection (you have to hit the larvae approximately 1-2 cm ahead of its track). System thiabendazole is typically noxious, as my patient discovered, and topical thiabendazole was not readily available.

Both systemically administered ivermectin and albendazole are effective in the treatment of CLM, although ivermectin appears superior and has the convenience of a single-dose regimen. In one recent report, ivermectin, administered as a single oral dose of 12 mg, was curative in 49 of 50 patients (two patients relapsed and were successfully retreated).2 The remaining patient, who was concurrently receiving corticosteroids and azathioprine for Crohn’s disease, failed multiple courses of therapy. In another report, albendazole, 400 mg once daily for seven days, was curative in all 11 patients with extensive disease.3 While shorter courses of albendazole (e.g., 3-5 days) may also be effective, data are lacking.

On the other hand, single-dose albendazole was an abysmal failure. Twenty-one patients were randomized to receive orally administered ivermectin (12 mg) or albendazole (400 mg) as a single dose. All 10 patients receiving ivermectin were completely cured of their infection, compared with one of 11 patients who failed albendazole and five who subsequently relapsed.4

On a slightly related note, SmithKline Beecham has signed a memorandum of understanding whereby SKB will donate albendazole to the WHO’s efforts to eliminate lymphatic filiarisis in third-world countries over the next 20 years. The Albendazole Donation Program complements Merck’s Ivermectin Donation Program for the WHO’s Onchocerciasis Control Program.

References

1. Jelinek T, et al. Cutaneous larva migrans in travelers: Synopsis of histories, symptoms, and treatment of 98 patients. Clin Infect Dis 1994;19:1062-1066.

2. Van den Enden E, et al. Treatment of cutaneous larva migrans. N Engl J Med 1998;339:1246-1247.

3. Rizzitelli G, et al. Albendazole: A new therapeutic regimen in cutaneous larva migrans. Int J Derm 1997;36: 703-703.

4. Caumes E, et al. A randomized trial of ivermectin versus albendazole for the treatment of cutaneous larva migrans. Am J Trop Med Hyg 1993;49:641-644.