Cutaneous Leishmaniasis

Cutaneous leishmaniasis (CL) is a skin infection caused by Leishmania species and transmitted by sandfly bites, producing ulcers or nodules.

• About 600,000 to 1 million new cases per year, mostly in Afghanistan, Syria, Iran, Algeria, Brazil, Colombia, and Peru.
• Old World: L. major (zoonotic, wet ulcer), L. tropica (anthroponotic, dry), L. aethiopica (East Africa, diffuse form). New World: L. braziliensis, L. mexicana, L. panamensis, L. guyanensis.
• Most lesions heal spontaneously over 3 to 18 months, leaving disfiguring scars.
• Variants: localised, diffuse, leishmaniasis recidivans, and disseminated.

• Painless papule at the bite site becomes a nodule then a well defined ulcer with raised indurated border and clean base (often "volcano" appearance).
• Lymphangitis with sporotrichoid nodules and regional lymphadenopathy (L. panamensis, L. braziliensis).
• L. aethiopica diffuse CL: non-ulcerating nodules and plaques, poor response to therapy.
• Secondary bacterial infection is common.

• Parasitological: Giemsa stained smear or scraping from the ulcer edge (amastigotes), biopsy, culture, and PCR for species identification (essential in New World disease for treatment decisions and mucosal risk).
• Leishmanin skin test (Montenegro) supportive.
• Exclude cutaneous TB, atypical mycobacteria, sporotrichosis, tropical ulcer, leprosy, yaws, pyoderma gangrenosum, and squamous cell carcinoma.

• Local therapy for uncomplicated Old World CL: cryotherapy with liquid nitrogen (1 to 2 freeze thaw cycles of 15 to 30 seconds every 2 to 3 weeks), thermotherapy (50 degrees Celsius for 30 seconds), intralesional sodium stibogluconate (1 to 5 mL per lesion weekly for 3 to 5 weeks), topical paromomycin 15% with methylbenzethonium chloride 12% twice daily for 20 days.
• Systemic therapy for complex lesions, multiple lesions, or high risk species:
  • Pentavalent antimonials (SSG or meglumine antimoniate) 20 mg/kg/day IM or IV for 20 days.
  • Liposomal amphotericin B 3 mg/kg/day on days 1 to 5 and day 10 (total 21 mg/kg; shorter courses for Old World).
  • Miltefosine 2.5 mg/kg/day for 28 days (effective for L. panamensis, L. guyanensis, L. braziliensis, less so for L. mexicana, L. major).
  • Fluconazole 200 mg daily for 6 weeks (L. major).
  • Pentamidine 3 to 4 mg/kg IM on alternate days for 3 to 4 doses (L. guyanensis).
• Wound care, treatment of secondary infection, and sandfly control (bed nets, repellents).