Skin Infections in Returned Travelers: an Update

  • Robert F. Zimmerman
  • Elizabeth S. Belanger
  • Christopher D. PfeifferEmail author
Skin, Soft Tissue, Bone and Joint Infectious Diseases (N Safdar, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Skin, Soft Tissue, Bone and Joint Infections


Dermatologic manifestations of travel-related illness are particularly vexing due to the broad differential diagnosis and clinicians’ unfamiliarity with uncommonly seen diseases. This paper aims to educate and update the reader on selected infectious diseases in the returned traveler whose disease manifestations are primarily dermatologic. First, the evolving epidemiology of these infections is examined; understanding the geographic distribution of infectious etiologies helps refine and narrow the differential diagnosis. This is followed by a discussion of six important clinical syndromes including cutaneous larva migrans (CLM), cutaneous leishmaniasis, tungiasis, myiasis, antibiotic-resistant skin and soft tissue infection, and selected infections associated with fever and rash (e.g., measles, chikungunya virus infection, dengue fever, rickettsial spotted fevers). Familiarity with these syndromes and a situational awareness of their epidemiology will facilitate a prompt, accurate diagnosis and lead to appropriate treatment and prevention of further disease spread.


Skin infection Travel medicine Cutaneous larva migrans Cutaneous leishmaniasis Tungiasis Myiasis Antibiotic resistance Skin and soft tissue infection Measles Chikungunya 


Compliance with Ethics Guidelines

Conflict of Interest

Elizabeth Belanger has no conflicts of interest. Christopher Pfeiffer received funding for other work from Oregon Health Authority.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.••
    Leder K, Torresi J, Libman MD, et al. GeoSentinel surveillance of illness in returned travelers, 2007-2011. Ann Intern Med. 2013;158(6):456–68. The most recent GeoSentinal review of the demographics, geography, and diseases associated with travel, an interesting read with great summary tables.CrossRefPubMedGoogle Scholar
  2. 2.
    Caumes E, Carriere J, Guermonprez G, Bricaire F, Danis M, Gentilini M. Dermatoses associated with travel to tropical countries: a prospective study of the diagnosis and management of 269 patients presenting to a tropical disease unit. Clin Infect Dis. 1995;20(3):542–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Lederman ER, Weld LH, Elyazar IR, et al. Dermatologic conditions of the ill returned traveler: an analysis from the GeoSentinel Surveillance Network. Int J Infect Dis. 2008;12(6):593–602.CrossRefPubMedGoogle Scholar
  4. 4.
    Bowman DD, Montgomery SP, Zajac AM, Eberhard ML, Kazacos KR. Hookworms of dogs and cats as agents of cutaneous larva migrans. Trends Parasitol. 2010;26(4):162–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Heukelbach J, Jackson A, Ariza L, Feldmeier H. Prevalence and risk factors of hookworm-related cutaneous larva migrans in a rural community in Brazil. Ann Trop Med Parasitol. 2008;102(1):53–61.CrossRefPubMedGoogle Scholar
  6. 6.
    Galanti B, Fusco FM, Nardiello S. Outbreak of cutaneous larva migrans in Naples, southern Italy. Trans R Soc Trop Med Hyg. 2002;96(5):491–2.CrossRefPubMedGoogle Scholar
  7. 7.
    Heukelbach J, Feldmeier H. Epidemiological and clinical characteristics of hookworm-related cutaneous larva migrans. Lancet Infect Dis. 2008;8(5):302–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Jelinek T, Maiwald H, Nothdurft HD, Loscher T. Cutaneous larva migrans in travelers: synopsis of histories, symptoms, and treatment of 98 patients. Clin Infect Dis. 1994;19(6):1062–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Centers for Disease Control and Prevention. Zoonotic Hookworm. Accessed 1 June 2014.
  10. 10.
    Bouchaud O, Houze S, Schiemann R, et al. Cutaneous larva migrans in travelers: a prospective study, with assessment of therapy with ivermectin. Clin Infect Dis. 2000;31(2):493–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Caumes E, Carriere J, Datry A, Gaxotte P, Danis M, Gentilini M. A randomized trial of ivermectin versus albendazole for the treatment of cutaneous larva migrans. Am J Trop Med Hyg. 1993;49(5):641–4.PubMedGoogle Scholar
  12. 12.
    Centers for Disease Control and Prevention. Leishmaniasis. Accessed June 1, 2014.
  13. 13.
    Clarke CF, Bradley KK, Wright JH, Glowicz J. Case report: emergence of autochthonous cutaneous leishmaniasis in northeastern Texas and southeastern Oklahoma. Am J Trop Med Hyg. 2013;88(1):157–61.CrossRefPubMedCentralPubMedGoogle Scholar
  14. 14.
    Arce A, Estirado A, Ordobas M, et al. Re-emergence of leishmaniasis in Spain: community outbreak in Madrid, Spain, 2009 to 2012. Euro Surveill. 2013;18(30):20546.PubMedGoogle Scholar
  15. 15.
    Lachaud L, Dedet JP, Marty P, et al. Surveillance of leishmaniases in France, 1999 to 2012. Euro Surveill. 2013;18(29):20534.PubMedGoogle Scholar
  16. 16.
    Gkolfinopoulou K, Bitsolas N, Patrinos S, et al. Epidemiology of human leishmaniasis in Greece, 1981-2011. Euro Surveill. 2013;18(29):20532.PubMedGoogle Scholar
  17. 17.
    Shirian S, Oryan A, Hatam GR, Panahi S, Daneshbod Y. Comparison of conventional, molecular, and immunohistochemical methods in diagnosis of typical and atypical cutaneous leishmaniasis. Arch Pathol Lab Med. 2014;138(2):235–40.CrossRefPubMedGoogle Scholar
  18. 18.•
    Centers for Disease Control and Prevention. Practical guide for laboratory diagnosis of leishmaniasis (2012). Accessed May 30, 2014. A very useful, straightforward step-by-step guide for the laboratory diagnosis of leishmaniasis available through the CDC, including specimen collection and shipping directions.
  19. 19.
    Dorlo TP, Balasegaram M, Beijnen JH, de Vries PJ. Miltefosine: a review of its pharmacology and therapeutic efficacy in the treatment of leishmaniasis. J Antimicrob Chemother. 2012;67(11):2576–97.CrossRefPubMedGoogle Scholar
  20. 20.
    Soto J, Arana BA, Toledo J, et al. Miltefosine for new world cutaneous leishmaniasis. Clin Infect Dis. 2004;38(9):1266–72.CrossRefPubMedGoogle Scholar
  21. 21.
    Centers for Disease Control and Prevention. DPDx: tungiasis. Accessed April 1, 2014.
  22. 22.
    Karunamoorthi K. Tungiasis: a neglected epidermal parasitic skin disease of marginalized populations—a call for global science and policy. Parasitol Res. 2013;112(10):3635–43.CrossRefPubMedGoogle Scholar
  23. 23.••
    Haddad Jr V, Cardoso JL, Lupi O, Tyring SK. Tropical dermatology: venomous arthropods and human skin: part I. Insect J Am Acad Dermatol. 2012;67(3):331 e331–314; quiz 345. A great summary for use in the evaluation of arthropod related skin lesions with pictures of rashes and the insects, applicable to both local patients and the returning traveler.Google Scholar
  24. 24.
    Lefebvre M, Capito C, Durant C, Hervier B, Grossi O. Tungiasis: a poorly documented tropical dermatosis. Med Mal Infect. 2011;41(9):465–8.CrossRefPubMedGoogle Scholar
  25. 25.
    Feldmeier H, Sentongo E, Krantz I. Tungiasis (sand flea disease): a parasitic disease with particular challenges for public health. Eur J Clin Microbiol Infect Dis. 2013;32(1):19–26.CrossRefPubMedGoogle Scholar
  26. 26.••
    Fydryszewski NA. Myiasis: diagnosis, treatment and medical use of maggots. Clin Lab Sci. 2013;26(2):76–81. A superb, succinct and practical discussion of myiasis from a clinical and laboratory standpoint.PubMedGoogle Scholar
  27. 27.
    Centers for Disease Control and Prevention. Myiasis. Accessed April 1, 2014. Accessed January 10.
  28. 28.
    Adehossi E, Parola P. A woman with a skin lesion. Myiasis Clin Infect Dis. 2009;48(11):1584. 1628-1589.CrossRefGoogle Scholar
  29. 29.
    West JK. Simple and effective field extraction of human botfly, Dermatobia hominis, using a venom extractor. Wilderness Environ Med. 2013;24(1):17–22.CrossRefPubMedGoogle Scholar
  30. 30.
    Stefani S, Chung DR, Lindsay JA, et al. Meticillin-resistant Staphylococcus aureus (MRSA): global epidemiology and harmonisation of typing methods. Int J Antimicrob Agents. 2012;39(4):273–82.CrossRefPubMedGoogle Scholar
  31. 31.
    Thati V, Shivannavar CT, Gaddad SM. Vancomycin resistance among methicillin resistant Staphylococcus aureus isolates from intensive care units of tertiary care hospitals in Hyderabad. Indian J Med Res. 2011;134(5):704–8.CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Rossi F, Diaz L, Wollam A, et al. Transferable vancomycin resistance in a community-associated MRSA lineage. N Engl J Med. 2014;370(16):1524–31.CrossRefPubMedCentralPubMedGoogle Scholar
  33. 33.•
    Molton JS, Tambyah PA, Ang BSP, Lin LM, Fisher DA. The global spread of healthcare-associated multidrug-resistant bacteria: a perspective from Asia. Clin Infect Dis. 2013;56:1310–8. A topical, up to date review article of the new international resistant bacterial pathogens on the horizon.CrossRefPubMedGoogle Scholar
  34. 34.
    Yong D, Toleman MA, Giske CG, et al. Characterization of a new metallo-beta-lactamase gene, bla(NDM-1), and a novel erythromycin esterase gene carried on a unique genetic structure in Klebsiella pneumoniae sequence type 14 from India. Antimicrob Agents Chemother. 2009;53(12):5046–54.CrossRefPubMedCentralPubMedGoogle Scholar
  35. 35.••
    Perry RT, Gacic-Dobo M, Dabbagh A, et al. Global control and regional elimination of measles, 2000-2012. MMWR Morb Mortal Wkly Rep. 2014;63(5):103–7. The most recent report on measles epidemiology and progress towards elimination.PubMedGoogle Scholar
  36. 36.
    Antona D, Levy-Bruhl D, Baudon C, et al. Measles elimination efforts and 2008-2011 outbreak. Fr Emerg Infect Dis. 2013;19(3):357–64.CrossRefGoogle Scholar
  37. 37.
    Centers for Disease C, Prevention. Progress toward the 2012 measles elimination goal—Western Pacific Region, 1990-2008. MMWR Morb Mortal Wkly Rep. 2009;58(24):669–73.Google Scholar
  38. 38.
    Bellini WJ, Helfand RF. The challenges and strategies for laboratory diagnosis of measles in an international setting. J Infect Dis. 2003;187 Suppl 1:S283–290.CrossRefPubMedGoogle Scholar
  39. 39.
    Centers for Disease Control and Prevention. Measles. Accessed June 10, 2014.
  40. 40.
    Centers for Disease Control and Prevention. Chikungunya. Accessed June 1, 2014.
  41. 41.
    Rezza G, Nicoletti L, Angelini R, et al. Infection with chikungunya virus in Italy: an outbreak in a temperate region. Lancet. 2007;370(9602):1840–6.CrossRefPubMedGoogle Scholar
  42. 42.
    Taubitz W, Cramer JP, Kapaun A, et al. Chikungunya fever in travelers: clinical presentation and course. Clin Infect Dis. 2007;45(1):e1–4.CrossRefPubMedGoogle Scholar
  43. 43.
    Raoult D, Roux V. Rickettsioses as paradigms of new or emerging infectious diseases. Clin Microbiol Rev. 1997;10(4):694–719.PubMedCentralPubMedGoogle Scholar
  44. 44.
    Centers for Disease Control and Prevention. Other tick-borne spotted fever rickettsial infections. Accessed June 1, 2014.

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Robert F. Zimmerman
    • 1
  • Elizabeth S. Belanger
    • 1
  • Christopher D. Pfeiffer
    • 1
    • 2
    Email author
  1. 1.Department of MedicineOregon Health & Science UniversityPortlandUSA
  2. 2.Department of Hospital and Specialty MedicinePortland Veterans Affairs Medical CenterPortlandUSA

Personalised recommendations