Skin diseases in returned

travelers

Pr. Eric CAUMES

Dept Maladies Infectieuses et Tropicales

Hop Pitié-Salpêtrière

Paris Sorbonne

University (ex Pierre & Marie Curie)

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Potential links of Interests

• In the past 5 years, I (or my department) have received

honoraria from BMS, Baxter, Galen, Codexial and

Takeda, for lectures on STDs and participation in

advisory boards (TBE vaccine, KS management,

permethrin, and dengue vaccine).

• Editor in Chief of the Journal of Travel Medicine

(submission wellcome) ESCMID eLibrary

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What is the part of tropical diseases

amongst skin diseases in returned

travelers seen in travel units?

• 1/ > 50%

• 2/ 35-50%

• 3/ 20-35%

• 4/ 5-20%

• 5/ < 5%5769

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0

10

20

30

40

50

60

1995 2007 2008 2014

Tropical

Tropical skin diseases in returning

travelers : less and less common

1995- Caumes E. Clin Inf Dis 1995; 20:542-548

2007- Ansart S. Am J Trop Med Hyg 2007; 76:184-186

2008- GeoSentinel. Int J Inf Dis 2008 i:10.1016/j.ijd.2007.12.008

2015- Stevens MS et al. CMAJ open 2015; 0.9778/cmajo.20140082

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What is/are the leading skin disease(s)

diagnosed in returning travelers seen

in travel units?

• 1/ cutaneous larva migrans

• 2/ skin and soft tissue infections

• 3/ sexually transmitted diseases

• 4/ insect bites and stings

• 5/ skin related animal exposures5768

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0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

SSTI Insecte prurit Animal LMCa

Derm

Skin diseases in 8.227 ill travelers

(19%), GeoSentinel, 2007-2011

Rabies

PEP

Leder K et al. Ann Intern Med 2013; 158: 456-468

Sentinel

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Dermatoses Canadian Travellers, 2009-2012

• 1076 dermatoses/6639 consultations (16%)

• 5/6 Canadian Sites; 6 possible purpose for travel

• Sex: 41% M; 58%F; age (IQR): 39.7 y (26-52)

• Travel duration (IQR): 15 d (7-31d)

• Outpatient: 1049 (97%)

• Carribean: 242 (22%); Latin America: 197 (18%)

• Tropical Infections (16.4%): HrCLM (9.8%);

LCL (3.3%); myiasis (1.7%); leprosy (1.4%)

Stevens MS et al. CMAJ open 2015; 10.9778/cmajo.20140082 ESCMID eLibrary

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What is the leading animal to which

travelers are exposed?

• 1/ Bat

• 2/ Dog

• 3/ Cat

• 4/ Monkey

• 5/ Tiger

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20

40

60

80

100

120

140

160

180

200

Insect bites (19%)

SSTI (14%)

HrCLM (9.8%)

Rash ukn (7.1%)

Prurit ukn (6%)

Animal (5.2%)

Skin problems in 1076 travellers Canada

Stevens MJ et al.

CMAJ open 2015

Sentinel

monkey (25), dog (18), other (10: bat

6, cat 3, tiger, stingray & leech 1)

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Skin diseases in returned travelers

(post travel and ID/travel unit biases)

• Epidemiological overview

• Skin and soft tissue Infections

• Hookworm related CLM,

creeping dermatitis

• Arthropodes exposure, pruritic

dermatoses ESCMID eLibrary

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What is the leading clinical form

of SSTI in returned travelers?

• 1/ cellulitis

• 2/ abscess

• 3/ impetigo

• 4/ furuncle

• 5/ folliculitis5771

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SSTI in 48 travelers, 1991 - 1993

• Impetigo : 19 (39%) - S aureus (40%)

[12 (63%) arthropod] - S.a + S.p (20%)

- S.pyogenes (20%)

- negative (20%)

• Erysipela : 9 (18%)

• Ecthyma : 8 (16%)

• Abscess: 4 (8%)

• Furoncle : 4 (8%)

• Intertrigo : 2 (4%)

• Folliculitis : 1 (2%)

• Necrotizing cellulitis : 1 (2%)

Caumes et al. Clin Inf Dis 1995;20:542-548 ESCMID eLibrary

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SSTI: from presentation to

treatment

Clinical form

Microbial agent

Presumptive treatment ESCMID eLibrary

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SSTI in 60 travelers, 01/2006 - 08/2007

Forms N (%) % culture + MS Sa GAS (Sp) Sa + Sp

Impetigo 21 (35%) 76% 31% 38% 31%

Abscess 14 (23%) 57% 100% 0 0

Ecthyma 11 (19%) 91% 10% 60% 30%

Cellulitis 11 (19%) 0 NA NA NA

Folliculitis 3 (5%) 33% 100% 0 0

Hochedez P et al. Am J Trop Med Hyg 2009; 80: 431-4

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M, 37 yo

D3 after bite

1. Furuncle

2.Folliculitis

3.Impetigo

4.Prurigo

5.Anthrax5772

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M, 43 yo, D2 after return

1.Furuncle; 2.Anthrax;

3.Impetigo; 4.Abscess; 5.Cellulitis

5773

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M, 32 yo

D3 after bite

1. Furuncle

2.Ecthyma

3.Impetigo

4.Anthrax

5.Cellulitis5774

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Traveling

MRSA

M, 37 yo

D3 > return

1. Furuncle

2.Anthrax

3.Impetigo

4.Cellulitis

5.Abscess5775

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Abscess management

« Ubi pus, Ibi evacuata »

Still true since

Hippocrate

Am J Med 1876; 6: 226 ESCMID eLibrary

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D 1 : arthropod bite

D 4 : lesion onset

D 6 : return;

D 7 : 1st consultation

F, 35 yo, D1

> Ivory Coast

D3 > onset

1. Furuncle

2.Folliculitis

3.Impetigo

4.Cellulitis

5.Abscess5776

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Cutaneous lesion appeared 6

days after N°1 went back

M, 41 yo

D3 > onset

1. Furuncle

2.Abscess

3.Impetigo

4.Cellulitis

5.Anthrax5777

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Mrs fistulized abscess Mr cellulitis

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Mr Abscess

& Mrs

fistulized abscess

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What is the bacteria most likely

involved in the SSTI of both

couples?

• 1/ Streptococcus pyogenes

• 2/ Staphylococcus aureus PVL +

• 3/ Streptococcus agalactiae

• 4/ Staphylococcus aureus PVL -

• 5/ Staphylococcus epidermidis

5778

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Import and spread of PVL+

S.aureus in travelers with SSTI• 38 travelers with S.aureus + SSTI vs 124 control with

other trav-dis; genotyping

• S.aureus SSTI were associated with travel duration and location (Africa: OR =4.2)

• Pts with PVL+ S.aureus SSTI were also colonized in the nares (73% vs 25%)

• SSTI due to PVL+ S.aureus were more likely to be complicated, have reduced antibiotic susceptibility and lead to 2ry spread (5 clusters)

Zanger P et al. Clin Inf Dis 2012; 54: 483-92

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S.aureus related SSTI in travelers

• Transmission in the household then in

the community

• Antibiotic resistance

• Recurrences

• Portage

Zhou YP, et al. J Travel Med. 2014; 21: 272-81

Zanger P (editorial). J Travel Med 2014; 21: 225-7 ESCMID eLibrary

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Palais des Papes

Avignon, France ESCMID eLibrary

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All these five patients presented

with creeping dermatitis, where

is the patient with loiasis ?

• 1/ Center

• 2/ Upper right

• 3/ Upper left

• 4/ Lower right

• 5/ Lower left

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Creeping eruption and CLMCreeping eruption

Not related to

parasitic

disease : lichen

striatus,

thrombophlebitis,

pili migrans,…

Related to the

migration of

parasite’s

larvae (incl

CLM):

animal

hookworm,

gnathostomiasis,

larva currens

Related to the

migration of

parasite :

scabies,

dracunculiasis,

loiasis, myiasis

Caumes E. Lancet Infect Dis

2004; 4: 659-660

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What is the most common cause

of creeping dermatitis in

returned travelers?

• 1/ Loiasis (nematode)

• 2/ Gnathostomiasis (nematode’s larvae)

• 3/ Hookworm related CLM (nematode’s larvae)

• 4/ Pyemotes ventricosus (arthropod)

• 5/ Larva currens (strongyloidiasis)(nematode)

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70 pts with creeping dermatitis, 2008-2012

Disease Number of cases (%)

HrCLM including

Hookworm folliculitis

66 (94%) including

7 HF /66 (11%)

Gnathostomiasis 2 (3%)

Loiasis 1 (1.5%)

Creeping (dog) hair 1 (1.5%)

Migratory myiasis,

dirofilariasis, larva currens,

Pyemotes ventricosus, scabies

0

Van Haecke C et al. Br J Dermatol 2014; 170: 1166-1169

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Boracay, Philippines ESCMID eLibrary

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What is the disease causing

creeping dermatitis with such a

parasitic cycle?

• 1/ Loiasis

• 2/ Gnathostomiasis

• 3/ Hookworm related CLM

• 4/ Pyemotes ventricosus

• 5/ Larva currens (strongyloidiasis)5783

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Folliculitis (HrCLM)

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Diagnosis of HrCLM relies on

1. Epidemiological data : typical exposure

2. Clinical appearance : creeping dermatitis (but also pruritic folliculitis)

3. Course of the disease : appearance less than one month after return, chronic

4. Biopsy of local lesion useless (except in folliculitis)

5. Stool examination : no interest except in ……dogs ESCMID eLibrary

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Hr Cut larva migrans in travellers

Ref (1) (2) (3)

Patients 60 67 64

Nationality Canada France France

After return 45 % 51 % 55 %

Lagtime 5d (0-30) 8d (0-28) 16d (1-120)

(1) Davies et al. Arch Dermatol 1993;129:588-591

(2) Caumes et al. Clin Infect Dis 1995;20:542-548

(3) Bouchaud et al. Clin Infect Dis 2000;31:493-498

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Identification of Ancylostoma braziliense in

HrCLM (Le Joncour A et al. Am J Trop Med Hyg 2012; 86:843-5)

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Le Joncour A et al. Am J Trop Med Hyg 2012; 86:843-5

Living hookworm larva recovered

from a skin scraping of folliculitis

Lesion (optical micro, x10)

hookworm larva

recovered

from a skin scraping

of folliculitis

lesion (optical

micro, x40)

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You can treat HrCLM patient

with…

• 1/ Ivermectine single or double dose

according to clinical presentation

• 2/ Albendazole 400 mg/d, 5 days

• 3/ Albendazole 800 mg/d, 3 days

• 4/ Albendazole 10% ointment

• 5/ Praziquantel5784

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Albendazole in HrCLM

Ref N= Dosage Cure rate

Coulaud, 1987 18 400 mg/d x 5 d 100%

Veraldi, 2011 78 400 mg/d x 7d 100%

Kaba, 2012 77 200-400 mg/d x 3 d 89%

Ref N= Dosage Cure rate

Jones, 1990 2 800 mg/d x 3 d 100%

Williams, 1989 4 800 mg/d x 3 d 100% ESCMID eLibrary

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HrCLM : efficacy of a single dose ivermectin

varies with the clinical presentation.

• 62 travellers (35 F, 27 M, mean age 35) with HrCLM

treated with 200 g/kg dose of ivermectin, single dose.

• All pts had creeping dermatitis and 6 patients (10%)

also had hookworm folliculitis (HF).

• Overall CR = 59/62 pts (95%). CR = 98% in the 56

pts presenting with only creeping dermatitis and

66% in the 6 patients also presenting with HF

Vanhaecke C et al. J Eur Acad Dermatol Venereol 2014; 28: 655-657 ESCMID eLibrary

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Topical albendazole in CLM : 2 pts

• 2 children, 10 kgs, 2 years old

• Return from Senegal, Dominican Republic

• 1 cutaneous lesion/pt

• ivermectin and albendazole contra indicated

• thiabendazole no more marketed

• albendazole ointment 10% (3 tablets, i.e. 1200 mg,

mixed with 12 gr crotamiton) twice a day during

10 days

Caumes E ; Clin Inf Dis 2004; 38: 1647-1648

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A traveler wants to know how to

avoid HrCLM on his next

vacation. Your advice to him is :

1. Use insect repellent

2. Sleep under bednets

3. Protect skin against direct sand/soil

exposure

4. Make dogs wearing sun glasses

5. Make dogs clean their shit5785

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Beppu, Japan

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Tokyo, Japan

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Borracay, Philippines

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Larva currens

Strongyloidiasis ESCMID eLibrary

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Creeping

Dermatitis

Loiasis

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Creeping dermatitis, loiasis

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Pruritic skin lesions

Pruritus

Localized Generalized

sine materia with skin

lesionsArthropod related

exposure

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What is the main cause of

generalized pruritus in a

returned traveler?

• 1/ Ciguatera

• 2/ HIV infection

• 3/ Onchocerciasis

• 4/ Scabies

• 5/ Marine dermatitis5786

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Generalized pruritus in

travelers (onset during travel)• Scabies

• Skin dryness (aged African migrants VFRs)

• HIV infection,

• Filariasis (onchocerciasis, loiasis), invasive phase of helminthic disease, African trypanosomiasis

• Ciguatera

• Cercarial dermatitis, Marine dermatitis ESCMID eLibrary

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What are the main itchy body

areas in a returned traveler w

scabies ?• 1/ Genitalia

• 2/ Breast

• 3/ Hands

• 4/ Head

• 5/ Back

5787

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Courtesy Antoine Mahé

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Scabies = 1st cause of pruritus

• Occurs within one month after exposure (1st

episode) and within a few days (history of previous

scabies)

• Generalized itching, worsen at night, sparing head

• Specific findings : 5 to 10 mm burrows,

vesiculopustules and papulonodular genital lesions.

Classic distribution : interdigital web spaces, flexor

surfaces of the wrists, elbows, axillae, buttocks,

genitalia and breast. ESCMID eLibrary

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Itching in the marital bed

is scabies …..before

……….. bedbugs

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Common scabies = treatment

• Varies according to the country

• Topical: either permethrin OR benzyl benzoate

• Oral : ivermectin

• To be repeated :

– D 2 for BB,

– D 7 for permethrin,

– D 7 for ivermectin

• Also include persons sharing the same household (sex/bed partners, children) and environment (clothes, bedsheets,…) ESCMID eLibrary

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Imported Tropical skin

infections• Seen according to the place of exposure :

HrCLM, LCL, tungiasis, myiasis,

• Uncommon : tuberculosis, leprosy,

gnathostomiasis, loiasis,

• Rare : M.ulcerans infection (Buruli ulcer),

anthrax, C.diphteriae, onchocerciasis, lymphatic

filariasis, cutaneous forms of schistosomiasis,

trypanosomiasis and amebiasis. ESCMID eLibrary

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Cutaneous diseases in

returned travellers

• Acquisition: arthropods bites

• SSTI are the most common

• Tropical diseases: less and less common

• Dg of skin disease oriented by epidemiologal data (visited country, time return/appearance, at-risk exposure), and clinical signs

• Dg confirmed by specific tests ESCMID eLibrary

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Thank you for your

attention and kind

invitation

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