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More Than Skin Deep
Abstract & Commentary
By Philip R. Fischer, MD, DTM&H
Professor of Pediatrics, Department of Pediatric and Adolescent Medicine, May Clinic, Rochester, MN.
Dr. Fischer reports no financial relationships to this field of study.
Synopsis: Despite advances in travel-related medications and immunizations, skin problems are still common among international travelers. Preventive behaviors, though not always well implemented, could be protective. Awareness of common skin problems associated with travel can assist providers in making accurate diagnoses and proposing effective treatments.
Source: Morris-Jones R, Morris-Jones S. Travel-associated skin disease. Infect Dis Clin N Am 2012; 26:675-689.
Almost anywhere in the world, insect bites can become uncomfortable entities. In sensitized individuals, allergic reactions can actually cause severe symptoms. The traveler does not usually have a specific recollection of being bitten, and bites usually have a central raised red area with surrounding paler erythema. Wound care is helpful to ensure cleanliness and decrease the risk of secondary infection, and symptomatic relief is available with oral antihistamines and topical corticosteroid creams. Future bites are usually avoidable by using repellents, insecticides, and barriers (clothes, nets).
Larvae can grow in human skin and cause myiasis, usually from Tumbu fly infections occurring in Africa and from botflies in Latin America. Covering the lesion(s) with oil for up to two hours causes the larvae to move out where they may be grabbed and removed with forceps. Tungiasis occurs when fleas develop in the skin; surrounding skin may be gently unroofed and the fleas extracted. Mites, such as scabies, burrow in the skin and can concurrently cause widespread pruritic lesions. Overnight application of topical treatments such as permethrin or malathion can be effective against scabies, but they should be repeated two weeks later since eggs might have survived the first treatment and continued to develop. Oral ivermectin is another treatment option. Cutaneous larva migrans results when animal hookworms happen to enter human skin; itchy serpiginous lesions result, and treatment with oral albendazole or ivermectin usually is effective.
Jellyfish stings are usually minor inconveniences, but stings from some jellyfish species lead to dangerous reactions. Immediate treatment usually involves rinsing the area with saltwater to remove nematocysts. Snake and scorpion bites can be uncomfortable; antivenom is required to treat severe systemic reactions to some species.
Symptomatic dengue fever can include both blanching and petechial rashes; supportive care is essential. Tick-borne illnesses can manifest themselves as peripheral rashes that become petechial; doxycycline is often effective treatment.
For 21 years, Travel Medicine Advisor has been informing travel medicine practitioners about the changing epidemiology of illness and about new advances in diagnostic methods and effective treatment. There has been progress. Some people practicing today barely remember a world without hepatitis A vaccines, mefloquine, and atovaquone-proguanil. Yet, during the past two decades, TMA informed readers about each of these then-new products. Compared to the time when TMA started, we are much better at preventing and treating many tropical illnesses. Beyond immunization and chemoprophylaxis, however, many other effective illness-preventing strategies require ongoing behavioral changes during trips, and this behavior modification is not easy.
A recent study of 152 traveling Dutch children identified insect bites as their most common travel-related ailment. Interestingly, 11% had bothersome bites prior to traveling, and 40% had bothersome bites during travel. Along with diarrhea (9% pre-travel and 30% during travel) and the common cold (6% pre-travel and 15% during travel), sunburn was another of the common ailments with 3% of Dutch children sunburned prior to travel and 19% having sunburn during travel.1 Whether at home or traveling, these skin problems could have been prevented with the use of insect repellents and sunscreen.
For years, fever, diarrhea, and skin problems have been major concerns in returned travelers.2 In a retrospective review of over 34,000 returned travelers who sought care at an outpatient travel clinic in Germany, 12% had skin problems.3 Specific causes include arthropods in 23%, bacteria in 22%, helminths in 11%, and protozoa in 6%.3 Similarly, skin problems ranked second only to diarrhea and were responsible for 25% of pediatric post-travel consultations in GeoSentinel-based travel clinics within 19 countries.4 Skin problems were particularly common in children returning from Latin America.4
Astute travel medicine practitioners will be aware of less common causes of dermatitis in travelers such as caterpillar stings5 and phytophotodermatitis from dribbled lime juice.6 But, the common travel-related skin problems should be preventable — with careful insect bite avoidance, use of sunscreen, and cleaning of sites of superficial traumatic injury.
The practice of travel medicine is advancing. What will shape travel medicine in the years to come? While continuing to build on successes in the battle against life-threatening illness, we will devote increasing efforts to counter leisure-limiting inconveniences. There will continue to be improvements in pre-travel medical interventions, but we should also pursue evidence-based during-travel behavioral modifications that prevent injuries and avoid inconveniences. Perhaps there will be new injections and prescriptions that somehow prevent insect bites, sunburns, and dermatologic infections and infestations. More likely, however, travel medicine will enter into a new era, an era during which health advice is translated into hour-by-hour and day-by-day implementation of health-promoting behaviors. Environmental enhancements will improve the health not just of travelers but, importantly, of local populations. International travel will increase, and health should improve for all.