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Treatment of CL

Because CL lesions are usually on the face, they cause disfiguration, stigma and discrimination. The goal of the treatment is to kill the parasite, control the spread of the lesion especially mucosal disease, accelerate healing and reduce scarring. Treatment is important cosmetically. Treatment should cure the patient and prevent relapse. There are several studies and case series reports on the treatment of L aethiopica in Ethiopia. However, these reports did not show a promising treatment option for CL in Ethiopia. The proposed treatment strategies are:

  1. Observation without drug treatment: Treatment is deferred if it is a single lesion, size less than 5cm, no mucosal involvement or close to mucosa (nose, lip, eyes), not on joints and if the patient is immunocompetent person. There is a chance for spontaneous healing in such small lesions in immune competent person in a period of six months. Thus, they can be followed with appointment every three months and reevaluated if treatment is needed.
  2. Local treatments: for smaller lesions but when withholding treatment is not an option local treatments can be tried. However, there are no studies comparing local treatments in terms of healing, scar size or duration of recovery with the other treatment options.

Local treatments can be:

  1. Intra-lesional SSG administration – Weekly intra-lesional SSG for 4-6 weeks. The injections should be given by experienced person directly on the lesion, not beneath or around the lesion. Injection is given using 1ml syringe, 0.2-0.5ml undiluted SSG at a time. Once the lesion is disrupted, upto 2ml SSG may be needed to infiltrate the residual thickened areas.
  2. Cryotherapy – Careful application of liquid nitrogen using a gun-shot equipment carefully only on the lesion. If liquid nitrogen is applied to a normal part of the skin, it can damage it. So meticulous care should be taken during application.
  3. Thermotherapy – Radio waves by thermomed devise produces 50˚C heat to be applied for 30 seconds on the lesion.
  4. Topical ointments – paromomycin ointment and gentamycin/paromomycin ointment option exist and have shown comparable efficacy as that ofintralesional SSG with about 70% cure rate in L major and L tropica regions.
  5. Curettage of lesion under local anesthesia – experiences from Pakistan showed good outcomes.
  6. Systemic treatment: MCL, DCL, CL close to mucosa, those lesions difficult for local treatment, more than four lesions, lesions with lymphangitis, CL in HIV and those patients who fail from local treatments all need systemic therapy. The systemic treatment options are:
    1. Paromomycin 15mg/Kg for 20-30days IM. Adverse events with paromomycin are pain at injection site, ototoxicity and nephrotoxicity.
    2. Sodium stibogluconate (SSG) 20mg/Kg IM/IV for 4-8weeks

The combination of SSG and paromomycin should be used to treat DCL cases and should be prolonged until skin slit smear become negative from LD bodies. 

  1. Miltefosine and Liposomal amphotericin B – Potentially useful but there is limited experience treating CL with these drugs.

Generally, there is limited experience and studies addressing the treatment of CL due to L aethiopica. Thus, there is an urgent need to perform trials to evaluate better treatment option for CL due to L aethiopica.  

Treatment response – Assessment of treatment response has to be followed with the size of an ulcer, re-epithelialization and flattening of nodules. Color change and scars may remain. Reactivation usually starts from the margins of the old lesion. Patients should be followed for six months after treatment. 

References:
van Griensven J, et al (2016) Treatment of Cutaneous Leishmaniasis Caused by Leishmania aethiopica: A Systematic Review. PLoS Negl Trop Dis 10(3)
Guidelines for diagnosis, treatment and prevention of leishmaniasis in Ethiopia, 2nd Ed. June 2013