Saturday, January 01, 2011
As with all infectious diseases, the diagnosis of leishmaniasis
should be established by identifying the causative agent in the
affected tissue by culture, scrapings, or biopsy. Response to
therapy is significantly related to the causative species and
geographic area in which the infection was acquired. Leishmaniasis
occurs in three forms: cutaneous, mucocutaneous, and visceral. Only
the therapy of cutaneous leishmaniasis is discussed here.
Old World Leishmaniasis
The following therapy may not apply to disease acquired in
Africa. Because mucocutaneous relapse is quite rare in Old World
Leishmaniasis, local therapy to the lesions alone is acceptable.
The natural history is one of spontaneous healing without therapy.
Treatment of lesions in cosmetically insignificant areas is not
If available, treatment is with paromomycin sulfate 15% and
methylbenzethonium chloride 12% in white soft paraffin applied
twice daily for 10 days.
- Chlorpromazine 2% ointment applied as above may also be
- Medical: Oral ketoconazole 400-1200 mg/day or rifampin (with or
without isoniazid) 600-1200 mg/day until healed.
- Surgical: Cryotherapy of individual lesions (forming an ice
ball 2 mm beyond the lesion). Surgical excision of solitary small
lesions may be curative.
- Intralesional antimony (80-100 mg/ml) on alternate days 3 times
per week, or once weekly for a minimum of 3 weeks, and at times for
several months will be effective in at least two thirds of
Use antimonial therapy as discussed below for New World
Leishmaniasis in Old World cutaneous disease only when standard
therapies fail and/or disease is progressive or disfiguring.
- Oral ketoconazole may cause hepatitis. Monitor liver function
- Oral rifampin will cause all body secretions to be colored
reddish brown. Hepatitis and thrombocytopenia may occur. Rifampin
reduces the efficacy of oral contraceptives.
- Delay for at least 1 year after apparent complete healing any
corrective plastic surgical procedures. During this period local
relapse may occur, destroying any benefit gained by the surgical
procedures; surgery can trigger reactivation of the infection.
New World Leishmaniasis (American Leishmaniasis)
Response to therapy is clearly species and subspecies related.
Mucocutaneous disease is a potential and disastrous complication of
New World Leishmaniasis. Treat cases acquired in areas where
mucocutaneous disease may occur with systemic agents. L.
braziliensis infection should be treated systemically. The CDC
will culture potentially infected tissue and speciate the infecting
parasite. In addition, they can advise you on the infectious
species present in the region where your patient was infected. This
information may be used to guide therapy, and will make antimonials
available for your patient, since the CDC must release the
medication (see CDC website).
- Treat patients with extensive cutaneous lesions or cutaneous
lesions acquired in an area endemic for L. braziliensis
with systemic antimonials (i.e., intramuscular or intravenous
sodium stibogluconate 20 mg/kg antimony for 20 days).
N-Methylglucamine antimonate 50-60 mg/kg/ day may also be used.
(Only sodium stibogluconate is available in the United States, and
it must be obtained from the Centers for Disease Control.)
- Patients with few lesions not acquired in an area endemic for
L. braziliensis may be treated with ketoconazole 400-1200
mg/day until healed.
Localized cutaneous lesions acquired in areas not endemic for
L. braziliensis may be treated with intralesional or
topical modalities used for Old World Leishmaniasis
- If the lesions have partially, but not completely responded
after a single course of systemic antimonial therapy, a second
(third, etc.) course may be given after a 10-day rest period.
Pentoxyphylline 400 mg 3 times daily may be added to the antimony
treatment for enhanced benefit.
- Patients failing to respond to antimonial therapy may be
treated with liposomal amphotericin B 3 mg/kg/day for days 1-5 with
additional doses at days 14 and 21.
- Antimonials are potentially quite toxic; electrocardiographic
changes, renal and liver toxicities, vomiting, and myalgias may
- Amphotericin B is nephrotoxic; monitoring renal function and
serum electrolytes (especially potassium) is required.
- Recurrence of apparently "healed" lesions may occur months
later, especially in patients treated with topical or intralesional
methods. Regular follow up of all patients diagnosed with cutaneous
leishmaniasis is recommended.