A 52-year-old male patient, with low socioeconomic status, retired due to disability because of an amputation at the level of the proximal third of the right lower limb due to a car accident six years ago, without comorbidities, reported lesions with intense local pruritus, with one year of evolution, located on the left foot, right lower limb stump and hands (Figure 1). He reported appearance of lesions soon after moving to a place where previously a pigsty was located, in a neighborhood on the periphery of the city of Campo Grande. At examination, papular-nodular-keratotic-crusty lesions were observed, with blackened central elevation, in large numbers, sometimes converging in extensive plaques in the heel and anterior dorsum, being fewer in the medial region of the left foot, dispersed in the fingers and on the right thigh stump. During initial evaluation, a flea transiting between the lesions was observed by dermoscopy. Anatomopathological examination revealed presence of a female of Tunga penetrans below the stratum corneum (Figure 2).

Figure 1 Lesions on most of the dorsum of the foot 

Figure 2 A. Dermoscopy of the lesion of the dorsum of the foot, evidencing the flea transiting between the lesions. B. Anatomopathological (Hematoxylin & eosin - X40), presenting the female flea on the skin 

Patient was initially medicated with ivermectin 6 mg, with prescription of 3 tablets/day for 7 days, and manual withdrawal of some lesions, according to literature.^1-3 On return, patient reported partial improvement of lesions, still complaining of pruritus and edema of extremities. Albendazole 400 mg/day for 7 days and amoxicillin 1.5 g/day for 10 days were instituted, together with left foot ankle cryotherapy and topical silver sulfadiazine in erosive-purulent lesions. Patient returned after 15 days, showing improvement of the lesions.