Worm infections skin signs B65-B83

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 20.05.2022

Synonym(s)

Helmet trousers; helminthiasis; helminthism

Definition
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Infections caused by worms are a worldwide medical problem that mainly affects Third World countries. With increasing tourism, however, they are also playing an increasingly important role in European countries and are thus gaining in importance for differential diagnosis.

Pathogen
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Overview see tab.

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Classification
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Basically, 2 pathogenetically different constellations can be defined from a dermatological point of view:

Nonspecific, reactive skin signs (dermadromas) to internal worm infestation:
- Chronic recurrent urticaria (caused by oxyuriasis, ascariasis, strongyloidosis, schistosomiasis, trichinosis, echinococcosis, among others).
- Angioedema: triggered by oxyuriasis, ascariasis, strongyloidosis, schistosomiasis, trichinosis, echinococcosis, among others.
- Periorbital oedema: e.g. in trichinosis.
- Eosinophilic skin lesions
- Dermatomyositis-like phenomena: e.g. in trichinosis or cysticercosis.
- Dicrocoeliasis: jaundice of the skin.
- Mansonelliasis: allergic reactions with pruritus, maculo-papular exanthema, urticaria, subcutaneous edema, lymph node swelling.
Specific skin signs due to worm invasion of the skin:
- Skin manifestations due to external skin invasion:
  - Larva migrans cutanea syndrome: including larvae of various roundworms.
  - Larva currens: special form of larva migrans caused by Strongyloides spp e.g. Strongyloides stercoralis .
  - Ankylostomiasis: common; caused by Ancylostoma duodenale[Old World hookworm] or Ancylostoma braziliense and Necator americanus [New World hookworm]; clinical: abdominal discomfort withiron deficiency anemia; dermatitis at site of larval penetration. In primarily animal pathogenic Ancylostama species, the clinical picture is that of larva migrans cutanea syndrome .
  - Cercarial dermatitis: larvae of mostly avian pathogenic trematodes as causative agent of the harmless swimmer`s itch (= bathing-trouser dermatitis) occurring in Europe and North America.
  - Cercarial dermatitis: by larvae of Schistosoma species as causative agent of schistosomiasis.
- Skin signs due to "secondary internal" skin invasion from a worm-infested other organ (e.g., intestinal tract or bladder):
  - Anal pruritus and pruritus vulvae: e.g. due to oxyuria(see below Oxyuriasis).
  - Dracunculosis: nematode infection with medina worm.
  - Cysticercosis: rare settlements of the pig tapeworm in the skin with formation of inflammatory nodules.
  - Filariasis: infections with tissue nematodes (threadworms) that parasitize in the skin.
  - Gnathostomiasis: infection by the nematode (roundworm) Gnathostoma spinigerum and/or Gnathostoma hispidum.
  - Echinococcosis: rare settlement of the dog tapeworm in the skin with formation of cysts up to the size of a fist.
  - Bilharzia: secondary skin infestation: usually genital and perigenital regions are affected with indolent, soft nodules and fistulas.

Clinical features
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Non-specific (often allergic) skin signs of internal worm infestation.
Specific skin signs due to invasion of the worms into the skin

Skin symptoms due to external skin invasion
Skin symptoms due to "internal" skin invasion from another organ affected by the worm (e.g. intestinal tract)

Therapy
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Overview see tab.

Tables
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Important pathogens of worm infections

	Helminths in the digestive tract	Lifespan/localization	Special features/ detection in stool or stool suspension/ infection route in endemic areas
Nematodes (roundworms or nematodes, 90% of diagnoses)	Ascaris lumbricoides (roundworm)	Months/ small intestine	Worm can be seen macroscopically (10-40 cm). Eggs not found until 9 weeks after infection, float in suspension. Infection often through consumption of uncooked leafy plants in endemic areas!
	Trichuris trichiura (whipworm)	several years/colon	Eggs float in suspension. Infection often through consumption of uncooked leafy plants in endemic areas!
	Enterobius vermicularis (pinworm) = oxyuras	Weeks/(re-infection!) Ileocecum	Worm to be detected macroscopically (10 mm). Eggs detectable by adhesive tape test at anus, float in suspension.
	Ancylostoma duodenale (hookworm)	several years/small intestine	Check for eggs after 8 weeks. Route of infection: skin-soil contact (warm, moist soils).
	Strongyloides stercolaris (dwarf nematode).	Small intestine	Do not use corticosteroids! Route of infection: skin-soil contact (warm, moist soils).

Cestodes (tapeworms, 9% of diagnoses).	Taenia saginata (bovine (fin) tapeworm)	several years/small intestine	Worm macroscopically detectable.
	Hymenolepis nana (dwarf tapeworm)	days (re-infection!)/Ileum	Infection by ingestion of eggs with contaminated food or as smear infection in poor hygienic conditions. Eggs can be detected microscopically.
	Diphyllobothrium latum (fish tapeworm)	several years/small intestine	Worm detectable macroscopically.

Trematodes (sucking worms or flukes, 1% of diagnoses).	Schistosoma mansoni, Schistosoma haematobium (couple flukes)	Decades/ mesenteric vessels.	Infection during bathing in fresh water.
	Clonorchis sinensis (Chinese liver fluke)	Decades/ bile ducts	Infection through consumption of raw fish.
	Fasciola hepatica (large liver fluke)	Decades/ bile ducts	Infection through contaminated drinking water or food (e.g., fallen fruit).
	Heterophyes heterophyes (dwarf intestinal fluke)	Decades/ small intestine	Infection through consumption of raw fish.

Therapy of worm diseases (modified after Simon/Stille)

Worm species	Antihelminthics	Comments	Alternatives
Ascaris	Pyrantel (e.g. Helmex) 10 mg/kg bw as single dose (max. 1 g)	NW: diarrhea, nausea, vomiting, not in pregnancy	Mebendazole (e.g. Vermox forte)
Enterobius	Pyrantel 10 mg/kg bw/day (max. 1 g), repeat after 1 week.	Frequent recurrences, treat family as well	Mebendazole, pyrvinium (e.g. Molevac)
Trichuris (whipworm)	Mebendazole adults and children: 2 times/day 100 mg for 3 days	NW: diarrhea, abdominal pain, not in gravidity.	Albendazole (e.g., Eskazole), ivermectin (e.g., Mectizan).
Trichinella	Mebendazole adults and children: 300 mg 3 times/day for 3 days, then 500 mg 3 times/day for 10 days.	Herxheimer reaction. Glucocorticoid porphylaxis e.g. prednisolone 40-60 mg/day.	Ivermectin
Hookworm (Ankylostoma duodenale)	Pyrantel (e.g., Helmex) once 10 mg/kg bw/day (max 1 g).	Gastrointestinal upset, fever, exanthema. Do not use pyrantel in liver dysfunction!	Mebendazole, Bephenium (Alcopar), Ivermectin
Larva migrans	10% Tiabendazole (e.g. Mintezol). Apply suspension locally
Toxocara	Diethylcarbamazepine (e.g., Hetrazan) 0.5 mg/kg bw/day for 3 days, then lgs. increase to 3 mg/kg bw/day for 21 days.	Only in severe disease and unfavorable localization (e.g., eye), if necessary additionally prednisolone in medium dosages (e.g., in hypoxia due to lung involvement)	Tiabendazole
Strongyloides (dwarf nematode)	Tiabendazole 2 times/day 25 mg for 3 days (max. 3 g/day).	Also treat asymptomatic forms	Mebendazole, albendazole
Filariae	Diethylcarbamazepine 3 times 2 mg/kg bw/day for 3 weeks.	Allergy due to lysis of parasites (fever, urticaria), possibly glucocorticoids internally.	Ivermectin
Dracunculus (Medina worm)	Metronidazole (e.g. Clont) 2 times/day 5 mg/kg bw/day for 1020 days or 2 times/day 25 mg/kg bw/day.	If possible, extraction of the worm	Tiabendazole
Taenia saginata, Taenia solium	Niclosamide (e.g., Yomesan) once 2 g; children 28 yrs.: 1 g; children < 2 yrs.: 0.5 g.	No purging, shedding of worm head necessary	Praziquantel
Cysticerci (fins of Taenia solium).	Praziquantel: 17 mg/kg bw/day in 3 ED for 14 days.	abdominal pain, headache, drowsiness, urticaria
Fish tapeworm (Diphyllobothrium latum).	Niclosamide 1 time 2 g, children: see above.	Possibly Vit. B12, no purging, removal of worm head necessary
Hymenolepsis nana (dwarf tapeworm)	Praziquantel (e.g. Cesol) once 25 mg/kg bw	abdominal pain and headache, dizziness, urticaria	Niclosamide
Echinococcus (dog tapeworm)	Mebendazole day 13: 2 times/day 500 mg p.o., day 46: 3 times/day 500 mg p.o., then 3 times/day 10001500 mg p.o. for 46 weeks for cystic E., for alveolar E. up to 2 years. Combination with praziquantel if necessary.	Parasitolysis with cyst rupture possible, often no complete elimination.	Surgery, albendazole
Bilharzia (Schistosoma mansoni).	Praziquantel once 40 mg/kg bw	abdominal pain and headache, dizziness, urticaria	Oxamniquine (e.g. Mansil)
Paragonimus (lung fluke)	Praziquantel 3 times/day 25 mg/kg bw for 2 days	abdominal pain and headache, dizziness, urticaria	Bithionol (e.g. Actamer)
Clonorchis (Chinese liver fluke)	Praziquantel 3 times/day 25 mg/kg bw, single dose	abdominal pain and headache, dizziness, urticaria
Fasciola hepatica	Bithionol (e.g. Bitin) 40 mg/kg bw every 2nd day, total 1015 doses	Nausea, vomiting, diarrhea, photosensitization, cardiotoxicity.

Spectrum of action of different chemotherapeutic agents (modified according to Forth)

Parasites	Tiabendazole (e.g. mintezole)	Pyrantel (e.g. Helmex)	Mebendazole (e.g. Vermox)	Ivermectin (e.g. Mectizan)	Pyrivinium (e.g. Molevac)	Bephenium (e.g. Alcopar)
Ascaris	++	+++	+++	+++	++	++
Enterobius	++	+++	+++	+++	+++	0
Trichuris	++	++	+++	+++	0	0
Hookworm	+++	+++	+++	+++	0	++
Strongyloides	+++	+	++	+++	0	+
Trichinella	0	0	++	+++	0	0
Larva migrans	+++	?	?	+++	0	0

Literature
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Enk CD et al (2003) Onchocerciasis. dermatologist 54: 513-517
Garcia HH et al (2004) A trial of antiparasitic treatment to reduce the rate of seizures due to cerebral cysticercosis. N Engl J Med 350: 249-258
Ito A et al (2003) Human Taeniasis and cysticercosis in Asia. Lancet 362: 1918-1920
Kern (1991) Extraintestinal helminthiases. Therapy week 41: 1074-1080
Ponnighaus JM et al (2001) Cutaneous manifestation of cysticercosis. dermatologist 52: 1098-1100
Simon C et al (1989) Antibiotic therapy. Schattauer Publishing House