Swimmer's itch

Swimmer's doack
Classification and external resources
Cercarial dermatitis on lower legs, four days after spending a day in the shallows of a lake.
ICD-10	B65.3
ICD-9	120.3
DiseasesDB	32723

Swimmer’s itch, also known as lake itch, duck itch, cercarial dermatitis,^[1] and Schistosome cercarial dermatitis,^[2]:432 is a short-term, immune reaction occurring in the skin of humans that have been infected by water-borne schistosomatidae. Symptoms, which include itchy, raised papules, commonly occur within hours of infection and do not generally last more than a week.

A number of different flatworm parasites in the family Schistosomatidae are what cause swimmer’s itch. These parasites use both freshwater snails and vertebrates as hosts in their parasitic life cycles. Mostly waterfowl are used as the vertebrate host. During one of their life stages, the larvae of the parasite, cercaria, leave the water snails and swim freely in the freshwater, attempting to encounter water birds. These larvae can accidentally come into contact with the skin of a swimmer. The cercaria penetrates the skin and dies in the skin immediately. The cercaria larvae cannot infect humans, but they cause an inflammatory immune reaction. This reaction causes initially mildly itchy spots on the skin. Within hours, these spots become raised papules which are intensely itchy. Each papule corresponds to the penetration site of a single parasite.

The schistosomatidae that give rise to swimmer’s itch should not to be confused with those of the genus Schistosoma, which infect humans and cause the serious human disease schistosomiasis, or with larval stages of thimble jellyfish (Linuche unguiculata), which give rise to seabather's eruption. Seabather's eruption mostly occurs in salt water, on skin covered by clothing or hair, whereas swimmer's itch mostly occurs in freshwater, on uncovered skin.^[3]

Since it was first described in Michigan in 1928,^[4] swimmer's itch has been reported from around the world. Some suggest incidence may be on the rise,^[5] although this may also be attributed to better monitoring.

Cause

The schistosomatidae genera most commonly associated with swimmer’s itch in humans are Trichobilharzia and Gigantobilharzia. Trematodes in these groups normally complete their life cycles in water birds. However, swimmer’s itch can also be caused by schistosome parasites of non-avian vertebrates, such as Schistosomatium douthitti, which infects snails and rodents. Other taxa reported to cause the reaction include Bilharziella polonica and Schistosoma bovis. In marine habitats, especially along the coasts, swimmer’s itch can occur as well. In Australia, the so called "pelican itch" is caused by cercariae of the genus Austrobilharzia employing marine gastropods of the genus Batillaria (B. australis) as intermediate hosts.

Life cycles of non-human schistosomes

The non-human schistosomes use two hosts in their life cycles. One is a snail, the other is a bird or mammal.

• Schistosomes are gonochoristic and sexual reproduction takes place in the vertebrate host. In genera that infect birds, adult worms occur in tissues and veins of the host’s gastrointestinal tract, where they produce eggs that are shed into water with host feces.

Note: One European species, Trichobilharzia regenti, instead infects the bird host’s nasal tissues and larvae hatch from the eggs directly in the tissue during drinking/feeding of the infected birds.^[6]

• Once a schistosome egg is immersed in water, a short-lived, non-feeding, free-living stage known as the miracidium emerges. The miracidium uses cilia to follow chemical and physical cues thought to increase its chances of finding the first intermediate host in its life cycle, a water snail.

• After infecting a snail, it develops into a mother sporocyst, which in turn undergoes asexual reproduction, yielding large numbers of daughter sporocysts, which asexually produce another short-lived, free-living stage, the cercaria.

• The cercariae (often forked in genera), who cause swimmer’s itch, use a tail-like appendage to swim to the surface of the water, as well as other physical and chemical cues, in order to locate the next and final (definitive) host in the life cycle, a bird.

• After infecting a bird, the parasite develops into a schistosomulum and migrates through the host’s circulatory system (or nervous system in case of T. regenti) to the final location within the host body where it matures and, if it encounters a mate, sheds eggs to begin the cycle anew.

Risk factors

Humans usually become infected with avian schistosomes after swimming in lakes or other bodies of slow-moving fresh water. Some laboratory evidence indicates snails shed cercariae most intensely in the morning and on sunny days, and exposure to water in these conditions may therefore increase risk. Duration of swimming is positively correlated with increased risk of infection in Europe^[7] and North America,^[8] and shallow inshore waters—snail habitat—undoubtedly harbour higher densities of cercariae than open waters offshore. Onshore winds are thought to cause cercariae to accumulate along shorelines.^[9] Studies of infested lakes and outbreaks in Europe and North America have found cases where infection risk appears to be evenly distributed around the margins of water bodies^[7] as well as instances where risk increases in endemic swimmer's itch "hotspots".^[9] Children may become infected more frequently and more intensely than adults but this probably reflects their tendency to swim for longer periods inshore, where cercariae also concentrate.^[10] Stimuli for cercarial penetration into host skin include unsaturated fatty acids, such as linoleic and linolenic acids. These substances occur naturally in human skin and are found in sun lotions and creams based on plant oils.

Control measures and treatment

Various strategies, targeting either the mollusc or avian hosts of schistosomes, have been used by lakeside residents in recreational areas of North America to deal with outbreaks of swimmer's itch. In Michigan, for decades authorities used copper sulfate as a molluscicide to reduce snail host populations and thereby the incidence of swimmer's itch. The results with this agent have been inconclusive, possibly because:

• snails become tolerant
• local water chemistry reduces the molluscicide's efficacy
• local currents diffuse it
• adjacent snail populations repopulate a treated area.^[11]

More importantly, perhaps, copper sulfate is toxic to more than just molluscs, and the effects of its use on aquatic ecosystems are not well understood.

Mechanical removal of snails in Lake Annecy, France

Another method targeting the snail host, mechanical disturbance of snail habitat, has been also tried in some areas of North America^[9] and Lake Annecy in France, with promising results.
Some work in Michigan suggests that administering praziquantel to hatchling waterfowl can reduce local swimmer's itch rates in humans.^[12] Work on schistosomiasis showed that water-resistant topical applications of the common insect repellent DEET prevented schistosomes from penetrating the skin of mice.^[13] Also 0.1-1% niclosamide formulation in water resistant sun cream or Safe Sea^TM cream protecting against jelly fish stings were shown to be highly reliable protectants, having lethal effect on schistosome cercariae.^[14] Public education of risk factors, a good alternative to the above-mentioned interventionist strategies, can also reduce human exposure to cercariae. Experience at Higgins Lake, Michigan, where systematic research on Swimmer's Itch was conducted in the 1990s, shows that periodic brisk toweling of the lower extremities is effective in preventing Swimmer's Itch.

Orally administered hydroxyzine, an antihistamine, is sometimes prescribed to treat swimmer's itch and similar dermal allergic reactions.

Other names

Swimmer's itch has various other names. In eastern nations, it is often named in reference to the rice paddies where it is contracted, producing names which translate to "rice paddy itch". For example, in Japan it is called "kubure" or "kobanyo", in Malaysia, "sawah", and in Thailand, "hoi con".

In the United States it is known to some as "duckworms" (in coastal New Jersey) or "clam digger's itch".

In certain parts of Canada, mainly Ontario, it is known as "Duck Lice" and "Beaver Lice".

In Australia it is known as "pelican itch".

In Western Minnesota, particularly on Lake Minnewaska, it is known as "lake itch."

See also

• Dermatitis
• Schistosomiasis
• Sea louse
• Seabather's eruption

References

1. ^ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 1-4160-2999-0. 
2. ^ James, William D.; Berger, Timothy G.; et al. (2006). Andrews' Diseases of the Skin: clinical Dermatology. Saunders Elsevier. ISBN 0-7216-2921-0. 
3. ^ Osment, Ls (Oct 1976). "Update: seabather's eruption and swimmer's itch.". Cutis; cutaneous medicine for the practitioner 18 (4): 545–7. ISSN 0011-4162. PMID 1017216. 
4. ^ Cort WW (1928). "Schistosome dermatitis in the United States (Michigan).". JAMA 90: 1027–9. 
5. ^ Hjorngaard Larsen A, Bresciani J, Buchmann K (2004). "Increasing frequency of cercarial dermatitis at higher latitudes". Acta Parasitologica 49 (3): 217–21. http://actaparasitologica.pan.pl/archive/49/toc49129.html. 
6. ^ Horák P, Kolárová L, Dvorák J (December 1998). "Trichobilharzia regenti n. sp. (Schistosomatidae, Bilharziellinae), a new nasal schistosome from Europe". Parasite 5 (4): 349–57. PMID 9879557. 
7. ^ ^{a b} Chamot E, Toscani L, Rougemont A (1998). "Public health importance and risk factors for cercarial dermatitis associated with swimming in Lake Leman at Geneva, Switzerland". Epidemiol. Infect. 120 (3): 305–14. doi:10.1017/S0950268898008826. PMC 2809408. PMID 9692609. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2809408. 
8. ^ Lindblade KA (1998). "The epidemiology of cercarial dermatitis and its association with limnological characteristics of a northern Michigan lake". J. Parasitol. 84 (1): 19–23. doi:10.2307/3284521. JSTOR 3284521. PMID 9488332. 
9. ^ ^{a b c} Leighton BJ, Zervos S, Webster JM (2000). "Ecological factors in schistosome transmission, and an environmentally benign method for controlling snails in a recreational lake with a record of schistosome dermatitis". Parasitol. Int. 49 (1): 9–17. doi:10.1016/S1383-5769(99)00034-3. PMID 10729712. 
10. ^ Verbrugge LM, Rainey JJ, Reimink RL, Blankespoor HD (2004). "Prospective study of swimmer's itch incidence and severity". J. Parasitol. 90 (4): 697–704. doi:10.1645/GE-237R. PMID 15357056. 
11. ^ Blankespoor HD, Reimink RL (1991). "The control of swimmer's itch in Michigan: Past, present, and future". Michigan Academician 24 (1): 7–23. 
12. ^ Blankespoor CL, Reimink RL, Blankespoort HD (2001). "Efficacy of praziquantel in treating natural schistosome infections in common mergansers". J. Parasitol. 87 (2): 424–6. doi:10.1645/0022-3395(2001)087[0424:EOPITN]2.0.CO;2. PMID 11318576. 
13. ^ Salafsky B, Ramaswamy K, He YX, Li J, Shibuya T (November 1999). "Development and evaluation of LIPODEET, a new long-acting formulation of N, N-diethyl-m-toluamide (DEET) for the prevention of schistosomiasis". Am. J. Trop. Med. Hyg. 61 (5): 743–50. PMID 10586906. http://www.ajtmh.org/cgi/pmidlookup?view=long&pmid=10586906. 
14. ^ Wulff C, Haeberlein S, Haas W (2007). "Cream formulations protecting against cercarial dermatitis by Trichobilharzia". Parasitol. Res. 101 (1): 91–7. doi:10.1007/s00436-006-0431-5. PMID 17252275. 

External links

• Information portal for NSF funded research on avian schistosome diversity
• CDC
• DermNet arthropods/swimmers-itch
• Links to pictures of swimmer's itch (Hardin MD/Univ of Iowa)
• Schistosome Group Prague, a member of the European Cercarial Dermatitis Network (ECDEN)
• Swimmer's Itch
• Wisconsin Department of Natural Resources, With warm weather, Swimmers Itch makes annual appearance