Cutaneous Leishmaniasis: More Treatment Options

I appreciated the excellent photograph of cutaneous leishmaniasis thatCPT Kenneth Brooks recently contributed to Photoclinic (CONSULTANT, June2004, page 1018, Figure). As a consequence of ongoing military actions in theMiddle East, American health care providers may well be called on to suspect,recognize, diagnose, and manage this tropical disease in those who have returnedto their home communities following active duty.While I would generally agree with CPT Brooks's comments regarding thelikelihood of spontaneous resolution of Old World leishmaniasis caused by Leishmaniamajor, it is important to point out that there are therapeutic alternatives tothe difficult-to-obtain pentavalent antimonial compounds.¹ Treatment maywell hasten resolution and reduce scarring. Certainly, no single drug or modalityhas proved consistently effective in every case or in every epidemiologic setting.Nonetheless, administration of relatively simple and safe treatments should be entertainedonce this diagnosis has been established. Among the newer interventionsa clinician might consider are:Topical imiquimod.Photodynamic therapy.Oral azithromycin.Oral azole antifungal compounds (in particular, fluconazole, 200 mg/d,appears to be quite effective²).---- Ted Rosen, MD
Professor of Dermatology
Baylor College of Medicine
Houston
Chief of Dermatology
Houston VA Medical Center
Dr Rosen's comments about alternatives to pentavalent antimonialcompounds are well taken. He offers several treatment options thatmilitary providers can initiate in the field--based on the clinical presentationof the lesion without polymerase chain reaction confirmation.While systemic antifungals are highly effective, their use is precludedin austere conditions where baseline liver function tests are unavailable.Since the parasite that causes the infection is susceptible to both heat and cold,cryotherapy in conjunction with topical antifungals can be used on suspiciouslesions with virtually no risk of hepatotoxicity.---- CPT Kenneth S. Brooks, PA-C
Camp As Sayliyah
Doha, Qatar

References:

REFERENCES:
1.

Koff AB, Rosen T. Treatment of cutaneous leishmaniasis.

J Am Acad Dermatol.

1994;31:693-708.

2.

Alrajbi AA, Ibrahim EA, De Vol EB, et al. Fluconazole for the treatment of cutaneous leishmaniasis causedby Leishmania major.

N Engl J Med.

2002;346:891-895.