Swimmer's itch

Swimmer's itch
Classification and external resources
File:Cercarial dermatitis lower legs.jpg 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 duck itch, cercarial dermatitis, and Schistosome cercarial dermatitis, 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.

The flatworm parasite schistosomatidae, that causes the swimmer’s itch, uses both freshwater snail and vertebrates, in this case mostly waterfowls, as hosts in their parasitic life cycles. During one of these life stages the larve, cercaria, swims freely in the fresh water looking for water birds and can accidentally hit the skin of the swimmer. The schistosomatidae dies in the skin immediately and cannot infect humans, but gives inflammatory, immune reactions. This gives initially mildly itchy spots on the skin. Within hours, these spots become raised papules that are more 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 fresh water, on uncovered skin.

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

Etiology

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.

• 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 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 and North America, 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. 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 as well as instances where risk increases in endemic swimmer's itch "hotspots". 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. 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.

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.

File:Lake Annecy.jpg

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 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. Work on schistosomiasis showed that water-resistant topical applications of the common insect repellent DEET prevented schistosomes from penetrating the skin of mice. 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.

Public education of risk factors, a good alternative to the above-mentioned interventionist strategies, can also reduce human exposure to cercariae.

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

A folk remedy is to use Rhubarb leaves dipped in water, which is rubbed on the skin of the affected area. The poison of the Rhubarb kills the parasites. Rhubarb leaves are poisonous however, and should not be ingested.

This folk remedy claims to kill the parasite, where the initial postulation of this article is that the parasite dies upon entering human skin. That a citation remains to be inserted after almost 12 months indicates this "folk remedy" information should be disregarded.

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 the Southeastern United States, specifically Tennessee, they are called "Chiggers", and are found in riparian areas where tall grass and water meet.

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

In Australia it is known as "pelican itch".

See also

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

External links

• 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

ar:حكة السباحين sv:Badklåda