Dermatologic Manifestations of Leishmaniasis Treatment & Management

  • Author: Peter J Weina, MD, PhD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jan 24, 2012
 

Medical Care

Tailor treatment to the individual because leishmaniasis is caused by many species or subspecies of the Leishmania protozoa, all of which have different degrees of virulence and clinical predilections. Consider the clinical pattern of disease, the geographic region in which the infection occurs, the immunologic status of the patient, and the previous attempts at treatment when therapy is started.

Although treatment was previously recommended for every case of leishmaniasis, this is no longer the conventional practice. Treatment must be a balance of risk versus benefit, especially in the case of Leishmania major from Iraq, which is generally a self-limited cutaneous illness that heals within 12 months, leaving minimal scarring. For lesions caused by this species, treatment is not generally necessary unless the lesion is in a cosmetically or functionally sensitive site. Cases due to Leishmania tropica (another Old World species) and some L major from certain regions of Afghanistan may have a more aggressive or chronic course (up to years); this organism (ie, L tropica) has been implicated in occasional cases of recidivans or viscerotropic leishmaniasis. As such, treatment may need to be more involved in cases caused by this species.

In New World leishmaniasis, estimates of recurrence range from less than 5% to as many as 10% of untreated individuals experiencing chronic ulcers, recidivans lesions, or mucocutaneous involvement. Because of this, treatment is very often the standard of care and parenteral therapy is usually the treatment of choice.

Multiple treatment options are used throughout the world for cutaneous disease. In addition to parenteral and oral medications (see Medication), local therapies for some forms of cutaneous leishmaniasis include (1) cryotherapy, (2) infiltration of sodium stibogluconate at 0.3-0.8 mL, (3) local heat therapy at 40-42°C (One novel FDA-cleared device is called the ThermoMed device; see Thermosurgery Technologies.), and (4) various topical paromomycin preparations, typically 15% with 10% urea.

Surgical excision is not usually recommended because of the risk of relapse and the cosmetic disfigurement. In some areas of the world (eg, Russia, Middle East), live-attenuated L major promastigotes have been used preemptively to immunize against Old World cutaneous leishmaniasis. This practice produces a modified form of the disease and results in a scar at the injection site. Immunity to subsequent L major infections usually is good; however, as with natural infection, cross-reactive immunity to other Leishmania species does not occur. Many more universally useful and cosmetically acceptable Leishmania vaccine formulations are under investigation. To date, no vaccines are commercially available.

Of primary importance in dealing with leishmaniasis is the treatment of malnutrition, concurrent systemic illness (eg, HIV disease, tuberculosis), or local infection (secondary bacterial). Despite successful clinical outcomes, the question of whether the parasites are completely eradicated is unclear because reactivation of leishmaniasis with immunosuppression has been reported.[12]

The guideline summary Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America may be of interest.[13]

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Consultations

Consult an infectious disease specialist.

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Diet

Advise patients to eat a nutritious diet.

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Contributor Information and Disclosures
Author

Peter J Weina, MD, PhD  Colonel, US Army; Director, Leishmania Diagnostics Laboratory, Walter Reed Army Institute of Research

Peter J Weina, MD, PhD is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, Association of Military Surgeons of the US, and International Society of Travel Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Abdul-Ghani Kibbi, MD  Professor and Chair, Department of Dermatology, American University of Beirut Medical Center, Lebanon

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD  Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The author and editors of eMedicine gratefully acknowledge the contributions of previous author, Julie R. Kenner, MD, PhD, to the development and writing of this article.

References

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Taxonomy of some of the medically important protozoans showing the relative relationship of the Kinetoplastida parasites generally, and Leishmania specifically.
Life cycles of the medically important Kinetoplastida illustrating the similarities and differences between the trypanosomes and Leishmania.
Sandfly. Courtesy of Kenneth F. Wagner, MD.
Comparison of a sandfly (left) and a mosquito (right). Their small size affects the efficacy of bed nets when used without permethrin treatment.
Cutaneous leishmaniasis. Courtesy of Kenneth F. Wagner, MD.
Classic Leishmania major lesion from a case in Iraq shows a volcanic appearance with rolled edges.
Atypical appearance of Leishmania major lesion with local spread beyond the borders of the primary lesion. Many of the lesions in cases from Iraq show an atypical appearance.
Cutaneous leishmaniasis with sporotrichotic spread.
While cutaneous leishmaniasis is generally considered to be an innocuous disease, this illustrates that in some parts of the world, especially in tribal areas, even cutaneous disease can have a life altering effect on a person's life.
Disseminated cutaneous leishmaniasis. Courtesy of Jacinto Convit, National Institute of Dermatology in Caracas, Venezuela.
Recidivans leishmaniasis. Courtesy of Kenneth F. Wagner, MD.
Post–kala azar dermal leishmaniasis. Courtesy of R. E. Kuntz and R. H. Watten, Naval Medical Research Unit, Taipei, Taiwan.
Mucocutaneous leishmaniasis. Courtesy of Kenneth F. Wagner, MD.
Mucocutaneous leishmaniasis. Courtesy of Kenneth F. Wagner, MD.
Visceral leishmaniasis. Courtesy of Kenneth F. Wagner, MD.
Amastigotes in a macrophage at 1000X magnification. Inset shows the cell membrane and points out the nucleus and kinetoplast, which are required to confirm that the inclusion seen in a macrophage is indeed an amastigote.
Free amastigotes near a disrupted macrophage. On touch preparations like this (Giemsa stain, original magnification X1000), the amastigotes are easier to identify than on other preparations. These stains clearly demonstrate the cell membrane, nucleus, and kinetoplast; all 3 are required for definitive diagnosis.
Free amastigote in a touch preparation (Giemsa stain, original magnification X1000).
Illustration of one form of the rK39 test for the serologic diagnosis of visceral leishmaniasis. It is an easy, very sensitive, and specific test for visceral disease. In this case, the dipstick second from the left shows a positive result and all the rest show reaction only at the control line.
 
 
 
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