Snapshot A 40-year-old man is alarmed by a snake-shaped lesion on his feet. The lesion migrates around 2 cm every day and his feet are extremely itchy. Three weeks ago, he returned from a beach vacation in the Caribbean, where he walked around barefoot in the sand. Introduction Cutaneous migratory infection caused by hookworm larvae most commonly Ancylostoma braziliense (hookworm of dogs and cats) others: Necator, Strongyloides Larvae must penetrate skin can migrate under skin “creeping eruption” transmitted via animal feces History is important here in tropical or subtropical regions typically 3 weeks after beach vacation involving sand children who play in sandboxes can be affected carpenters and plumbers who work under houses can be affected Presentation Symptoms very itchy migrates 2 cm daily Skin exam erythematous, elevated, serpiginous red-to-purple lesions commonly on feet and ankles can also affect buttocks, genitals, hands Non-skin findings Loeffler syndrome eosinophils accumulate in lungs in response to parasitic infection Evaluation Diagnosis by clinical history and exam skin biopsy typically not needed Laboratory values eosinophilia increased IgE levels Radiograph of chest if Loeffler syndrome is suspected patchy infiltrates Differential Diagnosis Allergic contact dermatitis Atopic dermatitis Scabies Treatment Medical treatment thiabendazole (topical) – first-line treatment albendazole (oral) ivermectin (oral) Prevention, and Complications Prevention avoid direct skin contact with fecally contaminated soil or sand Complications secondary infection causing cellulitis eczematous inflammation allergic reaction Loeffler syndrome (rare) Prognosis If untreated, larvae die on own in 2 - 8 weeks If treated, resolution occurs 2 - 3 days after therapy begins