Introduction 

Tungiasis is an infection that affects both humans and animals. It happens when the female sand flea or the jigger flea, scientifically called the Tunga penetrans or the Tunga trimamillata enters your skin, usually through the feet and lays its eggs while feeding into it. This causes swellings around the skin, making you experience pain and itching around the affected area. This makes it difficult for you to walk, sleep or concentrate.^1,2

These organisms are seen in tropical or subtropical areas like the Caribbean, Africa, and South America.³Theylive in dry, shaded, and sandy areas in these regions. The frequency of tungiasis is caused by financial hardship, housing made of earthen floors, inadequate hygienic facilities and association with livestock or pets.⁴

Tungiasis unevenly affects weaker individuals like children between 5-14 years and the elderly.  

What you need to know about Tungiasis

The lifecycle of Tungiasis

The organism that causes tungiasis is the female sand flea, when it bores into your skin, it lays many eggs in the skin wounds. These eggs fall to the ground after being expelled and develop into larvae after 3 to 4 days. The larvae feed on materials in the environment and develop through two phases (first and second instar phase) before proceeding to a pupal. It takes about three to four weeks for the pupae to become adult fleas.⁵

Symptoms

Several features are seen in people experiencing tungiasis, they include:¹

• Having difficulty  walking 
• Body pains
• Intense itching 
• Irritation and swelling
• Sores
• Blisters and inflammation

Complications 

Tungiasis can cause the following complications:

• Formation of pus-filled inflammation: There is a provocative reaction that occurs in the body in response to fleas that are enclosed under the skin, this can lead to the development of pus which are called abscesses, which may require surgery^1,6
• Wounds and tears: Chronic lesions can evolve into wounds and tears, causing significant pain and discomfort^1,6
• Inflammation and oedema of the lymph: Inflammation can spread to the lymph which may cause the lymph vessels to be inflamed and also retention of fluid in the lymph which may cause swelling of the lymph^1,6
• Tissue death and decay: Severe cases can result in tissue death (necrosis) and decay, which could be called necrosis and gangrene, particularly if there is a secondary bacterial infection^1,5
• Deformation and Loss of Nails: Chronic infestation may lead to deformities of the toes and nails, which can affect mobility and cause long-term disability^1,6
• Secondary bacterial infection: The sores created when the flea burrows into the skin are prone to bacterial infections, including potentially life-threatening conditions like blood sepsis, tetanus, and skin infection^2,5
• Chronic Pain and Disability: Patients often experience ongoing pain, which can cause difficulty in walking thereby reducing their movements and affecting their daily activities. This chronic pain can lead to serious impairment in quality of life⁷
• Social Stigmatization: Individuals with visible sores and lesions may face social stigma and exclusion, impacting their psychological well-being and community interactions^1,7

Treatment Approaches in Tungiasis

Mechanical removal

This involves the removal of the sand fleas that are living beneath the skin surgically by using sterile equipment and this procedure is done by trained healthcare professionals. In many indigenous areas, individuals often resort to using non-sterile tools (like needles or thorns) for self-removal.

Pharmacological (topical and systemic) treatment 

This intervention employs the use of drug substances to address tungiasis, therefore minimizing the effects on individuals experiencing tungiasis.:

• Topical Treatments: the tropical treatments utilise Dimethicone-based products and have shown to be effective in treating tungiasis by suffocating the fleas. Clinical trials reported significant success in reducing lesions and curing infestations without major adverse reactions.^8,9 There are other topical options which include Petrolatum and Ivermectin
• Systemic Treatments: this treatment option is oral medications like Ivermectin, Niridazole and Thiabendazole. They have been evaluated but are less commonly used compared to topical therapies due to varying effectiveness and potential side effects⁸

Topical Therapies for Tungiasis

Topical therapies for tungiasis aim to address the infection and reduce the symptoms of the disease. These therapies include antiparasitic,  antibacterial, antiseptic, anti-inflammatory, and pain relief agents. It also involves the use of barrier creams or occlusive dressings.

Antiparasitic Agents

• Topical Ivermectin: This topical medication has been proven to reduce the number of lesions caused by enclosed sand fleas in the skin. Ivermectin works by paralyzing and killing the parasites upon contact, therefore facilitating the removal of the fleas. A randomized controlled trial demonstrated that topical Ivermectin significantly reduced lesions compared to placebo treatments, highlighting its potential effectiveness in managing tungiasis¹⁰
• Thiabendazole: This topical agent has been evaluated for its efficacy against tungiasis. Studies indicate that Thiabendazole, whether in ointment or lotion form, can significantly reduce lesions¹⁰
• Metrifonate: It is also effective in decreasing the number of lesions caused by deep-seated sand fleas¹⁰

Antibacterial and Antiseptic Agents

• Chlorhexidine and Povidone-Iodine: These agents are antiseptics and they are used to prevent secondary infections following the removal of sand fleas. When applied they help to cleanse the affected part and reduce the risk of bacterial infections that can complicate tungiasis⁸

Anti-inflammatory and Pain-relief Agents

• Topical Corticosteroids: These can be applied to reduce inflammation and alleviate pain associated with tungiasis wounds and tears
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Topical NSAIDs provide symptomatic relief from pains and swellings

Barrier Creams and Occlusive Dressings

Barrier creams can help close lesions after flea removal, preventing further irritation and re-occurrence of the infections. Occlusive dressings may also protect the area from external contaminants while promoting healing.

Future directions

Future directions and innovations for the treatment of tungiasis focus on enhancing the effectiveness, affordability, and accessibility of topical agents, as well as integrating community-based interventions and education campaigns.

Development of more effective, affordable, and easily available topical agents

There is an ongoing research that aims to develop new topical formulations that are both effective against Tunga penetrans and affordable for communities in affected areas. For example, studies are exploring plant-based solutions like Zanzarin, which has shown to be able to reduce the infection rates and can as well be produced locally at lower costs.^12,13

Integration with community-based interventions and education campaigns

• Community engagement: Successful interventions have demonstrated the importance of engaging local communities in the fight against tungiasis. For example, a study in Nigeria that used community-led initiatives such as banning free-roaming pigs and improving living conditions showed that such interventions led to a significant reduction in prevalence from 45.2% to 21.3% within a year¹²
• Education Campaigns: Educating communities about hygiene practices, proper footwear use, and the importance of environmental sanitation can help reduce transmission rates. However, care must be taken to avoid stigmatization associated with hygiene practices¹⁴

Conclusion

Topical therapies play an important role in managing tungiasis by addressing both the infection and symptoms that are linked to it. The combination of antiparasitic agents with antibacterial measures and supportive treatments offers an all-inclusive approach to the treatment of endemic communities. Future directions for tungiasis treatment emphasize developing effective and affordable topical agents while integrating community engagement and education efforts.