Doctors Revision

Dermatology (Skin Conditions)

Tungiasis

Ectoparasitic skin infestation caused by the burrowing female sand flea, Tunga penetrans, typically affecting the feet.

Also known as: Jiggers, Sand Flea Infestation

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Referral and warning signs

When to refer

Refer if: Extensive infestation. Severe secondary infection. Complications like gangrene or tetanus suspected. Difficulty removing fleas safely.

Red flags

  • Signs of severe secondary infection (spreading cellulitis, fever, sepsis).
  • Signs of tetanus.
  • Gangrene.
  • Extremely heavy infestation causing significant disability.

Signs and symptoms

  • Initial lesion: Erythematous spot where flea penetrates.
  • Embedded flea appears as a whitish nodule (flea's abdomen swells with eggs) with a central black dot (posterior end of flea for breathing/defecation/egg release).
  • Lesions often painful and intensely itchy.
  • Inflammation, redness, swelling around the lesion.
  • Multiple lesions common, especially on feet (periungual areas, soles, heels, interdigital spaces), sometimes hands, elbows, buttocks.
  • Ulceration may occur.
  • Oozing of serosanguineous fluid or visible eggs from central punctum.
  • Difficulty walking due to pain.
  • Secondary bacterial infection common (pus, increased pain/swelling).

Risk factors

  • Walking barefoot in sandy soil/areas where flea is endemic.
  • Living in endemic areas (tropical/subtropical regions).
  • Poor housing conditions (earthen floors).
  • Close contact with infested domestic animals (pigs, dogs) or rodents.
  • Poverty, lack of access to footwear.

Diagnosis

Clinical assessment

Diagnosis based on characteristic appearance of embedded flea lesion (white nodule, black dot) in typical locations, often with history of exposure in endemic area.

Differential diagnosis

  • Scabies (burrows, different distribution).
  • Tick bite (retained mouthparts possible).
  • Other insect bites.
  • Myiasis (larval infestation).
  • Foreign body reaction.
  • Warts.
  • Bacterial abscess/paronychia.

Investigations

  • Usually clinical diagnosis only.

Management

Non-pharmacological management

  • Mechanical Extraction: Careful removal of the embedded flea using sterile instruments (needle, forceps, safety pin). Ensure entire flea is removed to prevent inflammation. Soak foot first to soften skin. (LOC: HC2)
  • Soaking: Soaking feet in antiseptic solution (e.g., Potassium Permanganate 0.05% solution daily for 10 min for 10 days - UCG option) may help soften skin and potentially kill flea/prevent infection.
  • Wound Care: Cleanse extraction site with antiseptic. Apply dressing if needed.
  • Suffocation (Alternative/Adjunct): Applying thick occlusive ointment (e.g., Petroleum jelly / Vaseline) or Dimethicone oil over lesion BID may suffocate the flea. (LOC: HC2)

Pharmacological treatment

  • Topical Agents:
  • - Benzyl Benzoate 25% emulsion applied BID for 6 days (UCG option). (LOC: HC2)
  • - Salicylic acid ointment (20% in petrolatum) applied daily for 7 days (UCG option).
  • - Dimethicone oil application (UCG option - apply drops to black dot, repeat after 10min).
  • Tetanus Prophylaxis: Ensure patient's tetanus status is up-to-date, booster if needed.
  • Antibiotics: Treat secondary bacterial infection if present (e.g., Cloxacillin - see Boil section 22.1.2). (LOC: HC2)

Monitoring

Monitor healing of extraction sites. Check for secondary infection. Assess for new lesions.

Complications

  • Severe pain, disability (difficulty walking).
  • Secondary bacterial infection (cellulitis, abscess, tetanus, gangrene).
  • Ulceration, tissue necrosis.
  • Nail deformity or loss.
  • Lymphangitis, lymphoedema.
  • Auto-amputation of digits (rare, severe chronic cases).

Prevention

  • Wearing closed shoes consistently in endemic areas.
  • Avoiding walking barefoot.
  • Regular foot inspection and cleaning.
  • Improving housing conditions (smooth floors vs earth).
  • Controlling animal reservoirs (treating infested pigs/dogs).
  • Spraying infested ground/floors with appropriate insecticides (e.g., Malathion).
  • Health education.

Patient education

  • Explanation of jiggers as burrowing fleas.
  • Importance of wearing shoes.
  • How to safely remove fleas or apply topical treatments.
  • Wound care after removal.
  • Recognizing signs of secondary infection.
  • Environmental control measures (floor spraying, animal control).

Uganda-specific notes

Tungiasis is a significant public health problem in certain districts, associated with poverty and lack of footwear. Causes considerable morbidity and stigma. Community-based control programs involving health education, treatment campaigns, and environmental measures are important.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 22, Section 22.4.3

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