Overview

Tungiasis is a parasitic skin disease that typically affects your feet and is caused by a flea known as Tunga penetrans, or sand flea. This sand flea burrows into the skin upon contact, leading to inflammation and itching, which can eventually disrupt sleep and daily life.¹ Children, in particular, have shown cognitive impairment due to tungiasis and may experience social exclusion and a reduced quality of life. In extreme cases, people may experience difficulty walking, loss of nails, and disfigured or mutilated feet.¹ This condition is most commonly found in people living in rural areas, especially those who do not wear footwear and have limited access to basic healthcare and sanitation.

In order to protect these vulnerable populations from tungiasis, prevention is essential.¹ Implementing and following appropriate prevention strategies can minimise pain and health issues, as well as lower the social and financial costs associated with the disease. Before exploring how to prevent this condition, it is important to first understand how it occurs.

Understanding tungiasis

What is tungiasis, and how is it transmitted?

The adult female sand flea, Tunga penetrans, is the causative agent of tungiasis. This flea is commonly found in tropical and subtropical areas of the Caribbean, South America, and sub-Saharan Africa. Older people and young children, particularly those between the ages of 5 and 14, are most likely to be affected.^1,2

The main transmission site is in homes with unsealed earthen floors. The eggs laid by the sand flea on the floor hatch into larvae, which take three to four weeks to mature into adult fleas. Adult fleas then seek a warm-blooded host for blood meals. Female fleas burrow into the skin, creating painful swellings and depositing up to 100 eggs before dying, thereby repeating the cycle.³ Due to the fleas' weak jumping ability, the majority of skin penetrations and resulting lesions occur on the toes, sole, or heel of the foot.⁴ The lesions appear as a black dot in the middle of a white patch.² Animal species have also been identified as reservoirs for human infection in certain regions, most commonly pigs and cows in rural locations, and dogs, cats, and rats in urban areas with limited resources.³

Factors contributing to tungiasis spread

Poor sanitation and hygiene

Tungiasis flourishes in places with poor sanitation. Unsanitary conditions and excess organic waste create ideal habitats for sand fleas. Infestation risk is further increased by inadequate access to clean water and poor hygiene practices, especially in regions affected by poverty.⁴

Lack of footwear

One of the main risk factors for tungiasis is going barefoot. In areas where walking without footwear is common due to financial constraints or cultural norms, people are more vulnerable to sand fleas in contaminated soil.⁵

Environmental conditions

Tropical and subtropical areas are ideal habitats for the sand flea, as it thrives in sandy soils and warm temperatures. Sandy, loose soil with high levels of animal activity enables the flea to complete its life cycle and sustain infestations in affected areas.^1,2

Treatment of tungiasis

Tungiasis should not be treated at home. Only a healthcare provider with sterilised tools and proven methods should remove a burrowed sand flea. Medical professionals can treat tungiasis by gently extracting the sand flea using sterile instruments such as a needle or forceps. In some cases, a small incision is required to ensure the entire flea is removed, as it expands while feeding. Other treatment options include applying antiparasitic creams such as ivermectin, metrifonate, and thiabendazole. Applying thick substances, such as wax or petroleum jelly, to the affected area may also be used to suffocate and kill the flea. Additionally, cryotherapy, a technique that freezes the flea and surrounding skin tissue to eliminate it safely, may be employed.^2,5

Prevention strategies

The occurrence of tungiasis can be reduced by following the prevention strategies described below.

Personal hygiene and protective measures

Maintaining good personal hygiene is essential to preventing tungiasis. Some of the best prevention strategies include:

• Maintaining clean skin: Washing your body daily with soap and water, including your feet after contact with contaminated soil, reduces the possibility of flea attachment
• Wearing protective footwear: Wearing sandals or closed-toe shoes protects the feet from contact with contaminated soil
• Covering footwear when travelling: If travelling to areas with a high prevalence of tungiasis, wearing fully covered shoes can help reduce the chance of infection
• Conducting regular body and foot inspections: Frequently examining the body and feet, particularly after walking in sandy areas, enables early detection and removal of fleas before they burrow deeper into the skin
• Using repellents: Regular use of coconut oil or neem oil-based repellent can effectively prevent fleas from penetrating the skin
• Applying Zanzarin: Studies have shown that using the plant-based insect repellent Zanzarin twice daily is more effective at preventing tungiasis than wearing shoes alone. Daily use of Zanzarin has been shown to be highly effective in providing protection against sand fleas in regions where they are prevalent^1,2,6,7,8

Environmental management

• Improving flooring: Replacing bare earth with concrete or tile flooring can considerably decrease indoor flea infestations. Using rugs or mats in sleeping areas is also beneficial
• Maintaining clean living areas: Regularly sweeping homes and outdoor areas and removing rubbish reduces flea breeding grounds. Laundering bedding on a regular basis is also recommended
• Using insecticides: Treating sand flea-infested areas with insecticides and managing infected animals that may spread the disease is advisable. For instance, the number of infections has decreased significantly in several communities with high tungiasis rates following malathion spraying. Methoprene, an insect growth regulator, is another useful option
• Topical aerosol treatment: Tungiasis can also be effectively treated using a topical aerosol comprising dichlorvos, gentian violet, and chlorfenvinphos
• Keeping school environments clean: Since this condition is more likely to occur in children, it is important to regularly clean classrooms in endemic areas to ensure they do not become breeding grounds for sand fleas
• Managing animals: Regular veterinary care and appropriate animal housing are essential, as pets and livestock can harbour fleas. Treating animals for fleas reduces the risk of human infection. Pigs, in particular, are frequent carriers of sand fleas^1,2,9,10

Community-based interventions

• Raising community awareness: Awareness-raising initiatives can educate communities on how to prevent the spread of tungiasis. Communication in local languages and the use of visual aids can enhance the effectiveness of health education
• Neighbourhood clean-up initiatives: Community-based efforts to collect organic waste and clean up high-risk locations can interrupt the flea's life cycle
• Providing hygiene resources: Giving individuals access to shoes, soap, and other personal hygiene necessities enables disadvantaged populations to better protect themselves against tungiasis^1,2,11

Medical and public health interventions

• Routine screenings: Frequent screenings in vulnerable populations can effectively reduce the occurrence of tungiasis. Health professionals can identify this condition early and prevent complications by conducting routine screenings in at-risk areas
• Timely medical care: Providing prompt medical attention to affected individuals decreases long-term harm and prevents secondary infections
• Government and NGO collaboration: Sustainable solutions can be achieved when governments and non-governmental organisations work together to carry out extensive interventions, such as distributing resources and providing educational materials^1,2,11

Summary

Tungiasis is a parasitic skin disease caused by Tunga penetrans that primarily affects individuals in tropical and subtropical regions where poor sanitation and environmental conditions favour flea survival. Effectively combating tungiasis requires a multifaceted strategy that combines personal, environmental, and community-based approaches. Personal preventive measures include wearing protective footwear, practising good hygiene, and using insect repellents such as Zanzarin. Environmental management, including cleaning living spaces, treating infested areas with insecticides, and improving housing conditions, also plays a crucial role in reducing incidence. Community-based initiatives such as hygiene kit distribution and preventive education help raise awareness, while timely treatment and routine medical check-ups can minimise adverse health outcomes.