A 54-year-old Brazilian farmer of low socioeconomic status came to our emergency center with generalized, pruritic lesions on the feet that had appeared 2 months earlier after working barefoot in a pigsty. These lesions consisted of multiple rounded, crusted, keratotic papules about the size of a nail head, with a raised blackish center, occasionally surrounded by yellowish discoloration, and even affected the nails (Fig. 1). The patient reported no other comorbidities, no previous conditions affecting the feet, and no family history of similar lesions.

Figure 1

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Tungiasis can affect both humans and pigs and is acquired in sandy locations and stables. It is a neglected parasitic skin disease resulting from permanent penetration by the female flea. It can be found in Africa, the Caribbean coast, and South America, and can also affect travelers visiting these areas. Only 2 species of flea infect humans: Tunga penetrans, which is the smallest known flea (1mm long); and Tunga trimamillata, a rarely described species found in the Peruvian Andes.1,2

The disease is self-limiting: the hematophagous female dies after ovulating in the skin of the host. Manual parasite removal is the standard treatment. Topical permethrin, oral thiabendazole, and oral ivermectin can also be used.2,3 After partial removal of the parasites on the day of the visit, our patient was treated with topical ointment consisting of 5% permethrin and 10mg/g of silver sulfadiazine twice daily for 10 days, resulting in successive extermination of the parasites and resolution of the lesions.