Cryosurgery in cutaneous leishmaniasis

From infection to vaccination: reviewing the global burden, history of vaccine development, and recurring challenges in global leishmaniasis protection

INTRODUCTION

Leishmaniasis is a major public health problem and the second most lethal parasitic disease in the world due to the lack of effective treatments and vaccines. Even when not lethal, leishmaniasis significantly affects individuals and communities through life-long disabilities, psycho-sociological trauma, poverty, and gender disparity in treatment.

AREAS COVERED

This review discusses the most relevant and recent research available on Pubmed and GoogleScholar highlighting leishmaniasis' global impact, pathogenesis, treatment options, and lack of effective control strategies. An effective vaccine is necessary to prevent morbidity and mortality, lower health care costs, and reduce the economic burden of leishmaniasis for endemic low- and middle-income countries. Since there are several forms of leishmaniasis, a pan-Leishmania vaccine without geographical restrictions is needed. This review also focuses on recent advances and common challenges in developing prophylactic strategies against leishmaniasis.

EXPERT OPINION

Despite advances in pre-clinical vaccine research, approval of a human leishmaniasis vaccine still faces major challenges - including manufacturing of candidate vaccines under Good Manufacturing Practices, developing well-designed clinical trials suitable in endemic countries, and defined correlates of protection. In addition, there is a need to explore Challenge Human Infection Model to avoid large trials because of fluctuating incidence and prevalence of leishmanasis.

Recent advances and new strategies on leishmaniasis treatment

Leishmaniasis is one of the most important tropical neglected diseases according to the World Health Organization. Even after more than a century, we still have few drugs for the disease therapy and their great toxicity and side effects put in check the treatment control program around the world. Moreover, the emergence of strains resistant to conventional drugs, co-infections such as HIV/Leishmania spp., the small therapeutic arsenal (pentavalent antimonials, amphotericin B and formulations, and miltefosine), and the low investment for the discovery/development of new drugs force researchers and world health agencies to seek new strategies to combat and control this important neglected disease. In this context, the aim of this review is to summarize new advances and new strategies used on leishmaniasis therapy addressing alternative and innovative treatment paths such as physical and local/topical therapies, combination or multi-drug uses, immunomodulation, drug repurposing, and the nanotechnology-based drug delivery systems.Key points• The treatment of leishmaniasis is a challenge for global health agencies.• Toxicity, side effects, reduced therapeutic arsenal, and drug resistance are the main problems.• New strategies and recent advances on leishmaniasis treatment are urgent.• Immunomodulators, nanotechnology, and drug repurposing are the future of leishmaniasis treatment.

Interventions for Old World cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis, caused by a parasitic infection, is considered one of the most serious skin diseases in many low- and middle-income countries. Old World cutaneous leishmaniasis (OWCL) is caused by species found in Africa, Asia, the Middle East, the Mediterranean, and India. The most commonly prescribed treatments are antimonials, but other drugs have been used with varying success. As OWCL tends to heal spontaneously, it is necessary to justify the use of systemic and topical treatments. This is an update of a Cochrane Review first published in 2008.

OBJECTIVES

To assess the effects of therapeutic interventions for the localised form of Old World cutaneous leishmaniasis.

SEARCH METHODS

We updated our searches of the following databases to November 2016: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). We wrote to national programme managers, general co-ordinators, directors, clinicians, WHO-EMRO regional officers of endemic countries, pharmaceutical companies, tropical medicine centres, and authors of relevant papers for further information about relevant unpublished and ongoing trials. We undertook a separate search for adverse effects of interventions for Old World cutaneous leishmaniasis in September 2015 using MEDLINE.

SELECTION CRITERIA

Randomised controlled trials of either single or combination treatments in immunocompetent people with OWCL confirmed by smear, histology, culture, or polymerase chain reaction. The comparators were either no treatment, placebo/vehicle, and/or another active compound.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias and extracted data. We only synthesised data when we were able to identify at least two studies investigating similar treatments and reporting data amenable to pooling. We also recorded data about adverse effects from the corresponding search.

MAIN RESULTS

We included 89 studies (of which 40 were new to this update) in 10,583 people with OWCL. The studies included were conducted mainly in the Far or Middle East at regional hospitals, local healthcare clinics, and skin disease research centres. Women accounted for 41.5% of the participants (range: 23% to 80%). The overall mean age of participants was 25 years (range 12 to 56). Most studies lasted between two to six months, with the longest lasting two years; average duration was four months. Most studies were at unclear or high risk for most bias domains. A lack of blinding and reporting bias were present in almost 40% of studies. Two trials were at low risk of bias for all domains. Trials reported the causative species poorly.Here we provide results for the two main comparisons identified: itraconazole (200 mg for six to eight weeks) versus placebo; and paromomycin ointment (15% plus 10% urea, twice daily for 14 days) versus vehicle.In the comparison of oral itraconazole versus placebo, at 2.5 months' follow up, 85/125 participants in the itraconazole group achieved complete cure compared to 54/119 in the placebo group (RR 3.70, 95% CI 0.35 to 38.99; 3 studies; 244 participants). In one study, microbiological or histopathological cure of skin lesions only occurred in the itraconazole group after a mean follow-up of 2.5 months (RR 17.00, 95% CI 0.47 to 612.21; 20 participants). However, although the analyses favour oral itraconazole for these outcomes, we cannot be confident in the results due to the very low certainty evidence. More side effects of mild abdominal pain and nausea (RR 2.36, 95% CI 0.74 to 7.47; 3 studies; 204 participants) and mild abnormal liver function (RR 3.08, 95% CI 0.53 to 17.98; 3 studies; 84 participants) occurred in the itraconazole group (as well as reports of headaches and dizziness), compared with the placebo group, but again we rated the certainty of evidence as very low so are unsure of the results.When comparing paromomycin with vehicle, there was no difference in the number of participants who achieved complete cure (RR of 1.00, 95% CI 0.86, 1.17; 383 participants, 2 studies) and microbiological or histopathological cure of skin lesions after a mean follow-up of 2.5 months (RR 1.03, CI 0.88 to 1.20; 383 participants, 2 studies), but the paromomycin group had more skin/local reactions (such as inflammation, vesiculation, pain, redness, or itch) (RR 1.42, 95% CI 0.67 to 3.01; 4 studies; 713 participants). For all of these outcomes, the certainty of evidence was very low, meaning we are unsure about these results.Trial authors did not report the percentage of lesions cured after the end of treatment or speed of healing for either of these key comparisons.

AUTHORS' CONCLUSIONS

There was very low-certainty evidence to support the effectiveness of itraconazole and paromomycin ointment for OWCL in terms of cure (i.e. microbiological or histopathological cure and percentage of participants completely cured). Both of these interventions incited more adverse effects, which were mild in nature, than their comparisons, but we could draw no conclusions regarding safety due to the very low certainty of the evidence for this outcome.We downgraded the key outcomes in these two comparisons due to high risk of bias, inconsistency between the results, and imprecision. There is a need for large, well-designed international studies that evaluate long-term effects of current therapies and enable a reliable conclusion about treatments. Future trials should specify the species of leishmaniasis; trials on types caused by Leishmania infantum, L aethiopica, andL donovani are lacking. Research into the effects of treating women of childbearing age, children, people with comorbid conditions, and those who are immunocompromised would also be helpful.It was difficult to evaluate the overall efficacy of any of the numerous treatments due to the variable treatment regimens examined and because RCTs evaluated different Leishmania species and took place in different geographical areas. Some outcomes we looked for but did not find were degree of functional and aesthetic impairment, change in ability to detect Leishmania, quality of life, and emergence of resistance. There were only limited data on prevention of scarring.

Interventions for Old World cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis, caused by a parasitic infection, is considered one of the most serious skin diseases in many low- and middle-income countries. Old World cutaneous leishmaniasis (OWCL) is caused by species found in Africa, Asia, the Middle East, the Mediterranean, and India. The most commonly prescribed treatments are antimonials, but other drugs have been used with varying success. As OWCL tends to heal spontaneously, it is necessary to justify the use of systemic and topical treatments. This is an update of a Cochrane Review first published in 2008.

OBJECTIVES

To assess the effects of therapeutic interventions for the localised form of Old World cutaneous leishmaniasis.

SEARCH METHODS

We updated our searches of the following databases to November 2016: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). We wrote to national programme managers, general co-ordinators, directors, clinicians, WHO-EMRO regional officers of endemic countries, pharmaceutical companies, tropical medicine centres, and authors of relevant papers for further information about relevant unpublished and ongoing trials. We undertook a separate search for adverse effects of interventions for Old World cutaneous leishmaniasis in September 2015 using MEDLINE.

SELECTION CRITERIA

Randomised controlled trials of either single or combination treatments in immunocompetent people with OWCL confirmed by smear, histology, culture, or polymerase chain reaction. The comparators were either no treatment, placebo/vehicle, and/or another active compound.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias and extracted data. We only synthesised data when we were able to identify at least two studies investigating similar treatments and reporting data amenable to pooling. We also recorded data about adverse effects from the corresponding search.

MAIN RESULTS

We included 89 studies (of which 40 were new to this update) in 10,583 people with OWCL. The studies included were conducted mainly in the Far or Middle East at regional hospitals, local healthcare clinics, and skin disease research centres. Women accounted for 41.5% of the participants (range: 23% to 80%). The overall mean age of participants was 25 years (range 12 to 56). Most studies lasted between two to six months, with the longest lasting two years; average duration was four months. Most studies were at unclear or high risk for most bias domains. A lack of blinding and reporting bias were present in almost 40% of studies. Two trials were at low risk of bias for all domains. Trials reported the causative species poorly.Here we provide results for the two main comparisons identified: itraconazole (200 mg for six to eight weeks) versus placebo; and paromomycin ointment (15% plus 10% urea, twice daily for 14 days) versus vehicle.In the comparison of oral itraconazole versus placebo, at 2.5 months' follow up, 85/125 participants in the itraconazole group achieved complete cure compared to 54/119 in the placebo group (RR 3.70, 95% CI 0.35 to 38.99; 3 studies; 244 participants). In one study, microbiological or histopathological cure of skin lesions only occurred in the itraconazole group after a mean follow-up of 2.5 months (RR 17.00, 95% CI 0.47 to 612.21; 20 participants). However, although the analyses favour oral itraconazole for these outcomes, we cannot be confident in the results due to the very low certainty evidence. More side effects of mild abdominal pain and nausea (RR 2.36, 95% CI 0.74 to 7.47; 3 studies; 204 participants) and mild abnormal liver function (RR 3.08, 95% CI 0.53 to 17.98; 3 studies; 84 participants) occurred in the itraconazole group (as well as reports of headaches and dizziness), compared with the placebo group, but again we rated the certainty of evidence as very low so are unsure of the results.When comparing paromomycin with vehicle, there was no difference in the number of participants who achieved complete cure (RR of 1.00, 95% CI 0.86, 1.17; 383 participants, 2 studies) and microbiological or histopathological cure of skin lesions after a mean follow-up of 2.5 months (RR 1.03, CI 0.88 to 1.20; 383 participants, 2 studies), but the paromomycin group had more skin/local reactions (such as inflammation, vesiculation, pain, redness, or itch) (RR 1.42, 95% CI 0.67 to 3.01; 4 studies; 713 participants). For all of these outcomes, the certainty of evidence was very low, meaning we are unsure about these results.Trial authors did not report the percentage of lesions cured after the end of treatment or speed of healing for either of these key comparisons.

AUTHORS' CONCLUSIONS

There was very low-certainty evidence to support the effectiveness of itraconazole and paromomycin ointment for OWCL in terms of cure (i.e. microbiological or histopathological cure and percentage of participants completely cured). Both of these interventions incited more adverse effects, which were mild in nature, than their comparisons, but we could draw no conclusions regarding safety due to the very low certainty of the evidence for this outcome.We downgraded the key outcomes in these two comparisons due to high risk of bias, inconsistency between the results, and imprecision. There is a need for large, well-designed international studies that evaluate long-term effects of current therapies and enable a reliable conclusion about treatments. Future trials should specify the species of leishmaniasis; trials on types caused by Leishmania infantum, L aethiopica, andL donovani are lacking. Research into the effects of treating women of childbearing age, children, people with comorbid conditions, and those who are immunocompromised would also be helpful.It was difficult to evaluate the overall efficacy of any of the numerous treatments due to the variable treatment regimens examined and because RCTs evaluated different Leishmania species and took place in different geographical areas. Some outcomes we looked for but did not find were degree of functional and aesthetic impairment, change in ability to detect Leishmania, quality of life, and emergence of resistance. There were only limited data on prevention of scarring.

Cutaneous Leishmaniasis in Saudi Arabia: A Comprehensive Overview

Despite the great efforts by health authorities in Kingdom of Saudi Arabia (KSA), Cutaneous leishmaniasis (CL) continues to be a major public health problem in the country. Many risk factors make KSA prone to outbreaks and epidemics; among these, rapid urbanization and the huge population movement are the most important. The disease is endemic in many parts of KSA, with the majority of cases concentrated in six regions, including Al-Qaseem, Riyadh, Al-Hassa, Aseer, Ha'il, and Al-Madinah. Leishmania major (L. major) and Leishmania tropica (L. tropica) are the main dermotropic species, and Phlebotomus papatasi (vector of L. major) and Phlebotomus sergenti (vector of L. tropica) are the proved vectors of the disease. Psammomys obesus and Meriones libycus have been defined as the principal reservoir hosts of zoonotic CL in Al-Hassa oasis, Al-Madinah, and Al-Qaseem provinces. Clinically, males are affected more than females, and there is no variation between the Saudis and expatriates in terms of number of reported cases, but the disease tends to run a more severe course among non-Saudis. Face is the most commonly affected site, and ulcerative pattern accounts for 90% of lesions. Despite local and international recommendations of using laboratory diagnostics to confirm CL cases, most cases in KSA are diagnosed and treated on clinical grounds and local epidemiology. However, systemic parenteral sodium stibogluconate (SSG) is the first line of therapy and used to treat all CL patients irrespective of their clinical presentation or the incriminated species. In brief, more efforts are needed to combat this disease. Several aspects of the disease require more evaluation through encouragement of national and regional studies. Development of evidence based national diagnostic and management guidelines, as well as algorithms, is urgently needed to improve the practice of diagnosing and treating CL in KSA.

Efficacy of cryotherapy for the treatment of cutaneous leishmaniasis: meta-analyses of clinical trials

BACKGROUND

Cryotherapy is a local treatment for cutaneous leishmaniasis with variable efficacy and greater safety than conventional treatment. The objective of this study is to evaluate the efficacy and safety of cryotherapy for the treatment of cutaneous leishmaniasis and to compare it with pentavalent antimonials.

METHODS

A meta-analysis based on a search of nine databases with eight strategies was conducted. Inclusion and exclusion criteria were applied, the methodological quality of each article was evaluated, and the reproducibility of the study selection and information extraction from each clinical trial was assured. The per lesion and per patient efficacy was calculated, and a meta-analysis of relative risks with the random effects model and the Dersimonian and Laird's, Begg, and Egger tests, along with a sensitivity analysis, were performed. A meta-regression based on the methodological quality of the trials included was also performed.

RESULTS

Eight studies were included in which respective per lesion efficacies of 67.3 % and 67.7 % were reported for cryotherapy and pentavalent antimonials. In 271 patients treated with cryotherapy and in 199 with pentavalent antimonials, respective per protocol and intent to treat efficacies of 63.6 % and 54.2 % were found in the first group, and per protocol and intent to treat efficacies of 74.7 % and 68.3 % were found in the second group. The relative risk for the comparison of efficacy in the two groups was 0.73 (0.42-1.29). The results of the sensitivity analysis and the meta-regression analysis of relative risks were statistically equal to the overall results.

CONCLUSION

This investigation provides evidence in favor of the use of cryotherapy given that its efficacy is similar to that of pentavalent antimonials.

Cutaneous and mucocutaneous leishmaniasis: Differential diagnosis, diagnosis, histopathology, and management

The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.

Topical Treatment Modalities for Old World Cutaneous Leishmaniasis: A Review

Diagnosis and therapy of cutaneous leishmaniasis (CL) can be difficult due to the variability of the clinical pictures and resistance to therapy. There is no vaccine currently available for CL. The aim of the present review is to describe different topical treatment modalities for old world CL. The mainstays of treatment for old world CL are pentavalent antimony compounds which are administered parenterally or intralesionally. New topical treatment alternatives have been available within the past few years. Amongst several treatments used topically, physical therapies including cryotherapy, heat therapy and CO2 laser are promising for the treatment of old world CL. Along with that, other randomized placebo controlled trials should be designed to find new effective therapeutic regimens.

Anti Leishmanial Effect of Zinc Sulphate on the Viability of Leishmania tropica and L. major Promastigotes

Background:

Cutaneous leishmaniasis (CL) is an endemic disease in developing countries. Although pentamidine orantimonite (Glucantime) has been recommended for cutaneous leishmaniasis treatment by the World Health Organization, there are some concerns too such as high cost, side effects, need for frequent injections, and restricted efficacy. Therefore, different methods have been used for CL treatment so far.

Objectives:

This study assessed the sensitivity of two parasite agents of cutaneous leishmaniasis: Leishmania major and L. tropica to zinc sulphate in vitro. In the present study, the zinc sulphate effect on urban and rural strains of cutaneous leishmaniasis, viability of old world, in vitro is under investigation.

Materials and Methods:

The design of the present study was experimental (laboratory-trial) based. Iranian endemic species of L. major and L.tropica were appropriately collected, proliferated, and maintained in the standard culture. Afterward, the proper concentrations of zinc sulphate were provided, sterilized, and added to the cultures containing parasites. In different intervals, parasites were counted by two methods: the slide and cell proliferation ELISA.

Results:

Both parasite species showed sensitivity to zinc sulphate in vitro and in comparison with the control group, their numbers were reduced. Zinc sulphate (in concentrations of 0.5, 1, 2, and 3 percent) was added to the cultures containing parasites, and the total number of the live parasites was counted through the slide method (Neubauer slide) every day up to the fifth day. The results were analyzed and found statistically significant (P < 0.05). In the second phase, the counting process was repeated with the addition of zinc sulphate compound with different concentrations (3, 4, 5, and 6 percent) and live parasite numbers were counted by ELISA method after 24 hours. The findings revealed that all the cultures containing zinc sulphate showed a slower growth in comparison to the control group. The mentioned difference was statistically significant (P < 0.05).

Conclusions:

Considering the safety of zinc sulphate compound in comparison with Glucantime, there is a possibility of using it in the treatment of CL caused by both species of L. major and L. tropica. It is obvious that more researches are mandatory both in vivo and in vitro to figure out its daily dosage, proper concentration, time and duration, and possible side effects.

Therapeutic options for old world cutaneous leishmaniasis and new world cutaneous and mucocutaneous leishmaniasis

Estimated worldwide incidence of tegumentary leishmaniasis (cutaneous leishmaniasis [CL] and mucocutaneous leishmaniasis [MCL]) is over 1.5 million cases per year in 82 countries, with 90 % of cases occurring in Afghanistan, Brazil, Iran, Peru, Saudi Arabia and Syria. Current treatments of CL are poorly justified and have sub-optimal effectiveness. Treatment can be based on topical or systemic regimens. These different options must be based on Leishmania species, geographic regions, and clinical presentations. In certain cases of Old World CL (OWCL), lesions can spontaneously heal without any need for therapeutic intervention. Local therapies (thermotherapy, cryotherapy, paromomycin ointment, local infiltration with antimonials) are good options with less systemic toxicity, reserving systemic treatments (azole drugs, miltefosine, antimonials, amphotericin B formulations) mainly for complex cases. The majority of New World CL (NWCL) types require systemic treatment (mainly with pentavalent antimonials), either to speed the healing or to prevent dissemination to oral-nasal mucosa as MCL (NWMCL). These types of lesions are potentially serious and always require systemic-based regimens, mainly antimonials and pentamidine; however, the associated immunotherapy is promising. This paper is an exhaustive review of the published literature on the treatment of OWCL, NWCL and NWMCL, and provides treatment recommendations stratified according to their level of evidence regarding the species of Leishmania implicated and the geographical location of the infection.

Cutaneous leishmaniasis: cryosurgery using carbon dioxide slush in a resource-poor country

Leishmaniasis is a widespread parasitic disease seen most often in children and young adults, although it may occur at any age. In Yemen, up until now, specific treatment for cutaneous leishmaniasis (CL) has been challenging. Available chemotherapy is expensive and replete with significant side effects. Standard cryosurgery with liquid nitrogen is prohibitively expensive and often unavailable. The objective of this paper is to highlight the importance of cryosurgery with carbon dioxide slush in the treatment of CL in an economically underdeveloped region as a cost-effective, simple, successful, and affordable option.

Successful treatment of canine cutaneous leishmaniasis using radio-frequency induced heat (RFH) therapy

Canine cutaneous leishmaniasis (CCL) is a significant veterinary problem. Infected dogs also serve as parasite reservoirs and contribute to human transmission of cutaneous leishmaniasis (CL). Current treatments for CCL are cumbersome and toxic because they are prolonged and involve multiple injections of antimonials. Radio-frequency induced heat (RFH) therapy has been found to be highly effective against CL in humans. Here, we examined the efficacy of topical RFH therapy in the treatment of CL in two pet dogs. We found that RFH therapy induced complete clinical cure and lesion healing within 45 days and both dogs have remained disease free for the last 16 months. This report is the first to demonstrate that a single topical application of RFH therapy is safe and effective in inducing long-term cure of CCL.

Is topical nitric oxide and cryotherapy more effective than cryotherapy in the treatment of old world cutaneous leishmaniasis?

BACKGROUND

Current systemic treatments for cutaneous leishmaniasis are limited by their toxicity, high cost, side effects and the emergence of drug resistance. New approaches, including topical therapies, are urgently needed. Nitric oxide (NO) produced by human and canine macrophages has long been demonstrated to be involved in the intracellular killing of Leishmania.

OBJECTIVE

This study was designed to determine the clinical responses (healing, or non-healing) and effectiveness of NO plus cryotherapy for the treatment of old world cutaneous leishmaniasis (CL).

METHODS

A double-blind, randomized, placebo-controlled clinical trial was performed for the evaluation of therapy with topical nitric oxide 3% and cryotherapy in 63 Iranian patients with CL in the south of Iran.

RESULTS

Thirty of 36 participants (83.3%) had complete improvement in the treatment group as did 20 of 27 (74.1%) from the control group (p = 0.627). Erythema, a burning sensation and irritation occurred in seven participants from the treatment group and one patient from the placebo group (p = 0.063).

CONCLUSION

This study could not show any more effectiveness from combining a 12-week course of treatment with 3% nitric oxide cream and a once-weekly treatment with cryotherapy in comparison with cryotherapy and placebo in patients with CL.

Thermotherapy in dermatologic infections

The use of local induced hyperthermia or thermotherapy for dermatologic infections has not been fully explored in the more recent medical literature. Herein, we discuss the rationale behind the use of thermotherapy and review reported clinical experience with its use in the management of cutaneous infections.

Tropical medicine rounds: Treatment of Old World cutaneous leishmaniasis with dapsone, itraconazole, cryotherapy, and imiquimod, alone and in combination

BACKGROUND

Cutaneous leishmaniasis (CL) is a major public health problem. The currently available therapies are expensive, not freely available, toxic, and not always curative. A simple, effective, noninvasive therapeutic approach is required for the treatment of CL.

AIMS

To determine the clinical patterns of CL and to report our experience in the management of CL.

METHODS

One hundred and ten patients with CL seen between January 2005 and December 2007 were included in this study. The diagnosis was based on clinical features, parasitologic diagnosis, histopathology, and culture. Each patient was treated according to disease severity with either topical (cryotherapy or imiquimod) or systemic (itraconazole or dapsone) monotherapy, or a combination of these modalities.

RESULTS

CL was more common in adult expatriate men, with the upper limbs as the most commonly affected site. Noduloulcerative CL was the most common presentation (84.6%). Atypical CL was found in 18 patients. Skin biopsy was the most common diagnostic technique (66.6%). Monotherapy showed an overall success rate of 56.41%, whereas combination therapy was successful in 69.56% of cases. Cryotherapy alone was successful in 68.18% of cases. Imiquimod alone was ineffective.

CONCLUSION

A stepwise approach represents a rational and practical way of confirming CL. A combination of itraconazole/dapsone and topically applied imiquimod is safe, simple, and effective for the treatment of CL. More studies are needed to establish the role of such an approach. Cryotherapy is also safe, simple and effective for the treatment of CL.

Interventions for Old World cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis is caused by a parasitic infection and is considered one of the most serious skin diseases in many developing countries. Antimonials are the most commonly prescribed treatment but other drugs have been used with varying success.

OBJECTIVES

To assess the effects of treatments for Old World cutaneous leishmaniasis (OWCL).

SEARCH STRATEGY

We searched the Cochrane Skin Group Specialised Register (April 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2008), MEDLINE (2003-April 2008), EMBASE (2005-April 2008), CINAHL (1982-August 2007), LILACS (from inception to April 2008) and ongoing trials databases (August 2007).

SELECTION CRITERIA

Randomised controlled trials assessing treatments in immuno-competent people with OWCL confirmed by smear, histology, culture or polymerase chain reaction.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data.

MAIN RESULTS

We included 49 trials involving 5559 participants. Reporting quality was generally poor and only two studies contained sufficiently similar data to pool.In Leishmania major infections, there was good RCT evidence of benefit of cure around 3 months after treatment when compared to placebo for 200 mg oral fluconazole (1 RCT n = 200, RR 2.78; 95% CI 1.86, 4.16), topical 15% paromomycin + 12% methylbenzethonium chloride (PR-MBCL) (1 RCT n = 60, RR 3.09; 95% CI 1.14, 8.37) and photodynamic therapy (1 RCT n = 60, RR 7.02; 95% CI 3.80, 17.55). Topical PR-MBCL was less efficacious than photodynamic therapy (1 RCT n = 65, RR 0.44; 95% CI 0.29, 0.66). Oral pentoxifylline was a good adjuvant therapy to intramuscular meglumine antimoniate (IMMA) when compared to IMMA plus placebo (1 RCT n = 64, RR 1.63; 95% CI 1.11, 2.39)In Leishmania tropica infections, there was good evidence of benefit for the use of 200 mg oral itraconazole for 6 weeks compared with placebo (1 RCT n = 20, RR 7.00; 95% CI 1.04, 46.95), for intralesional sodium stibogluconate (1 RCT n = 292, RR 2.62; 95% CI 1.78, 3.86), and for thermotherapy compared with intramuscular sodium stibogluconate (1 RCT n = 283, RR 2.99; 95% CI 2.04, 4.37).

AUTHORS' CONCLUSIONS

Most trials have been designed and reported poorly, resulting in a lack of evidence for potentially beneficial treatments. There is a desperate need for large well conducted studies that evaluate long-term effects of current therapies. We suggest the creation of an international platform to improve quality and standardization of future trials in order to inform clinical practice.

Efficacy of a weekly cryotherapy regimen to treat Leishmania major cutaneous leishmaniasis

BACKGROUND

Antileishmanial chemotherapy can have adverse effects and may fail to cure patients with cutaneous leishmaniasis (CL).

OBJECTIVE

To evaluate the efficacy of a weekly cryotherapy regimen in patients with confirmed Leishmania major infection.

METHODS

One hundred twenty Jordanian patients with 375 lesions were treated with cryotherapy performed once weekly in 1 to 7 sessions. This regimen was adopted since living parasites were recovered, in several CL patients, even after 3 cryosessions. Scarring was assessed in 78 patients 3 years after treatment.

RESULTS

Approximately 84% of the lesions were cured after 1 to 4 sessions. The remaining lesions (16.3%) were cured after an additional 1 to 3 session(s). Cryotherapy caused mild adverse side effects and most of the patients were cured with negligible scarring. Statistically, the lesion size and location significantly affected the clinical response to cryotherapy.

LIMITATIONS

A fraction of patients was followed up 3 years after healing.

CONCLUSION

Cryotherapy with weekly intervals for 1 to 4 sessions is effective to treat L major CL, especially for smaller lesions. Extra sessions may be necessary to cure larger lesions. The cosmetic results are very good and no relapses were registered.

Cutaneous leishmaniasis: Clinical report of two cases and review of the recent literature

With 1-1.5 million cases reported every year cutaneous leishmaniasis represents an increasing health problem. The course of cutaneous leishmaniasis varies from a single self-healing ulcer to a persistent ulcer or progressive mucosal disease with nasopharyngeal destruction. An enormous array of topical and systemic treatment modalities has been endorsed. The response to treatment depends on the species of parasite as well as the host's immunological and genetic status. Species-specific treatment guidelines based on evidence from controlled studies are highly desirable. We present two cases of cutaneous leishmaniasis, one in a child and one during pregnancy, reviewing various diagnostic and therapeutic measures with special attention to problems in young and pregnant patients.

Leishmaniasis

Epidemiology, disease patterns, immunology, diagnosis, treatment and control measures of leishmaniasis are described. Various issues relating to leishmaniasis are highlighted: the relative lack of importance given to this disease compared with other infections, climate change and its possible impact on extension of endemicity of this infection, and new diagnostic tests which are improving diagnosis, especially in resource poor areas. Other important aspects discussed include the potential for newer oral therapy to change the way this disease is managed; Leishmania-HIV coinfection and groups at risk; and development of an effective vaccine.

Therapeutic options for cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis occurs worldwide in both old and new world countries with their own endemic foci. Many of those infected often experience a delay in diagnosis and inappropriate treatment.

OBJECTIVES

To review the literature in terms of the various treatment options described for cutaneous leishmaniasis.

METHODS

Literature on the treatment of cutaneous leishmaniasis retrieved by searching Index Medicus, PubMed and IndMed were reviewed.

RESULTS AND CONCLUSION

Review reveals no uniform pattern or definite guidelines for its therapy. The varied and contradictory experience of different workers further confounds the clinicians involved in the care of these patients. Selection of an appropriate and customized treatment schedule is a discretion the treating clinician has to make.

Leishmaniasis

Epidemiology, disease patterns, immunology, diagnosis, treatment and control measures of leishmaniasis are described. Various issues relating to leishmaniasis are highlighted: the relative lack of importance given to this disease is compared with other infections, climate change and its possible effect on extension of endemicity of this infection, and new diagnostic tests that are helping better diagnosis, especially in resource-poor areas. Other important aspects discussed include the potential for newer oral treatment to change the way this disease is managed; leishmania-HIV coinfection and groups at risk; and the development of an effective vaccine.

Cutaneous leishmaniasis in soldiers from Fort Campbell, Kentucky returning from Operation Iraqi Freedom highlights diagnostic and therapeutic options

BACKGROUND

Cutaneous leishmaniasis (CL), rare in the first Gulf War, is common in American troops serving in Operation Iraqi Freedom. Awareness of the clinical features and treatment options of CL would benefit clinicians who may encounter soldiers, as well as civilians, returning from the Middle East with skin lesions.

OBJECTIVE

Our purpose was to describe our clinical experience in treating soldiers with CL.

METHODS

From December 2003 through June 2004, approximately 360 of an estimated 20,000 soldiers returning from a yearlong deployment in Iraq with skin lesions suspected of being CL were examined by dermatologists. We summarized CL diagnoses, laboratory evaluations, and treatments, including localized heat therapy (ThermoMed model 1.8; ThermoSurgery Technologies, Inc, Phoenix, Ariz), oral fluconazole, cryotherapy, and itraconazole.

RESULTS

Among 237 soldiers diagnosed with CL, 181 had one or more laboratory confirmations, most by Giemsa-stained lesion smears and polymerase chain reaction (PCR). PCR was positive for all 122 smear-positive and 26 biopsy-positive lesions and all 34 smear negative and all 3 biopsy-negative cases. Primary outpatient treatments, including ThermoMed (n = 26), oral fluconazole (n = 15), cryotherapy (n = 4), and itraconazole (n = 2), were safe and tolerable. Treatment failure occurred in 2 fluconazole recipients and was suspected in 1 ThermoMed and 2 fluconazole recipients. Seventy-two soldiers elected no treatment.

LIMITATION

This was a retrospective study.

CONCLUSION

Approximately 1% of Ft Campbell troops returning from Iraq were diagnosed with CL, most by laboratory confirmation. PCR appeared to be the most useful diagnostic technique. Among outpatient treatments, ThermoMed and cryotherapy had favorable safety and efficacy profiles.

Cutaneous leishmaniasis: successful treatment with itraconazole

BACKGROUND

Leishmaniasis is a disease produced by several species of protozoa of the Leishmania genus. These protozoa are injected into the human bloodstream by sandflies. The symptomathology, either cutaneous, mucocutaneous or visceral, depends on the infective species and the immune status of the patient. Antimonial drugs are the mainstay treatment for all the clinical forms of the disease. Amphotericin B is the second-choice drug.

METHODS

We report two clinical cases of cutaneous leishmaniasis treated with itraconazole. One case was a relapsing form unresponsive to conventional therapy.

RESULTS

Both patients achieved fast resolution of their lesions with no secondary effects.

CONCLUSIONS

Itraconazole may be a valid option for the treatment of cutaneous leishmaniasis, mainly in those cases unresponsive to conventional drugs.

Immunotherapy, immunochemotherapy and chemotherapy for American cutaneous leishmaniasis treatment

The first choice of treatment for American cutaneous leishmaniasis is the pentavalent antimonial drug. Although it has been shown that this treatment is mostly effective and indicated, some disadvantages should be taken into account such as side effects, long term treatment inconveniences and counter-indication for patients suffering from cardiopathy, nephropathy; yet, aging, pregnancy and other conditions. With the advent of the vaccine anti-American cutaneous leishmaniasis as a prophylactic measure, studies on therapy using the vaccine associated or not with other drugs have been performed by many investigators and it is currently among the alternative treatments and prevention measures for American cutaneous leishmaniasis. In conclusion, the association between antimony and vaccine (immunochemotherapy) showed the same cure rate when compared with the standard treatment (100%) and it was also able to reduce the salt volume in 17.9% and treatment length from 87 to 62 days, decreasing side effects.

Treatment of cutaneous leishmaniasis with cryosurgery

BACKGROUND

The management of cutaneous leishmaniasis with topical methods, if effective, can spare patients from long and costly inpatient treatments.

METHODS

Seventeen patients with cutaneous leishmaniasis were treated with cryosurgery using liquid nitrogen as the cryogen. Two cycles of 10-30 s freezing time were used and repeated at 3-week intervals.

RESULTS

All patients responded well to therapy with excellent cosmetic results and no relapse in any case. Side-effects were rare.

CONCLUSIONS

Cutaneous leishmaniasis can be successfully treated with a simple protocol of cryosurgery with minor side-effects.

Leishmaniasis: early diagnosis is key

A patient presents with nasal congestion, a history of nosebleed, and painful lesions on his body and in his mouth. What questions should you ask to ensure that you make an accurate diagnosis?

Cutaneous leishmaniasis in the returning traveler

Infection with protozoan parasites of the genus Leishmania leads to a wide variety of clinical disease syndromes called leishmaniasis, or more appropriately the leishmaniases. The three major clinical syndromes are cutaneous leishmaniasis, mucosal leishmaniasis, and visceral leishmaniasis. All three of these syndromes have been documented in returning travelers. This article focuses on cutaneous leishmaniasis with some comment on mucosal leishmaniasis.

Old World Leishmaniasis: An Emerging Infection among Deployed US Military and Civilian Workers

Many veterans of Operation Iraqi Freedom are now returning to the United States after potential exposure to leishmaniasis. In the past year, large numbers of leishmaniasis cases of a magnitude not encountered in the United States since World War II have challenged clinicians in both the military and the civilian sectors. Many Reserve and National Guard troops were deployed to Iraq and are now back in their communities. Hundreds of leishmaniasis cases, which were managed by a few practitioners initially, permitted further appreciation of the epidemiology and diagnostic and treatment options for Old World leishmaniasis. We describe the current situation, with on-the-ground experience, complimented by a literature review, and we provide a practical list of options for the clinician likely to encounter this parasitic infection in the coming months and years.

Comparative study of the efficacy of combined cryotherapy and intralesional meglumine antimoniate (GlucantimeR) vs. cryotherapy and intralesional meglumine antimoniate (GlucantimeR) alone for the treatment of cutaneous leishmaniasis

BACKGROUND

Cutaneous leishmaniasis (CL) is a parasitic disease caused by Leishmania species. There is a need for more effective and less time-consuming therapeutic methods for this condition.

AIM

To evaluate the efficacy of combined cryotherapy and intralesional meglumine antimoniate (MA) (Glucantime, Specia, Paris, France) for the treatment of CL.

METHODS

Patients were divided into three groups: Group 1, 100 patients with 149 lesions were treated with cryotherapy plus intralesional MA; Group 2, 200 patients with 230 lesions were treated with cryotherapy; Group 3, 100 patients with 160 lesions were treated with intralesional MA. These groups were followed for 6 months after the end of treatment.

RESULTS

The results showed complete cure in 90.9% of cases in Group 1, 57.15% of cases in Group 2, and 55.63% of cases in Group 3. The difference between Group 1 and the other groups was statistically significant (P < 0.05).

CONCLUSIONS

Combined cryotherapy and intralesional MA is more effective than either cryotherapy or intralesional MA alone for the treatment of CL.

Histologic cure of basal cell carcinoma treated with cryosurgery

BACKGROUND

Cryosurgery is a method of treatment for basal cell carcinoma (BCC). Despite numerous studies reporting excellent cure rates with cryosurgery, there are no studies in the literature that have shown a histologic cure of BCC.

OBJECTIVE

We sought to show histologically that cryosurgery is an effective cure for well-defined, noduloulcerative BCC of the trunk and upper extremities.

METHODS

Twelve noduloulcerative BCCs of the trunk and proximal upper extremities less than 1 cm were treated with single freeze-thaw cryosurgery using a cryoprobe apparatus with liquid nitrogen. A thermocouple needle measured temperature, with the goal to reach between -50 degrees C and -60 degrees C. One to 2 months later, the site was excised and examined with horizontal step sections throughout the entire tissue.

RESULTS

No tissue specimens had histologic evidence of tumor.

CONCLUSION

Single freeze-thaw cryosurgery provides a histologic cure of well-defined, noduloulcerative BCCs of the trunk and extremities less than or equal to 1 cm.

The efficacy of treatment with intralesional meglumine antimoniate alone, compared with that of cryotherapy combined with the meglumine antimoniate or intralesional sodium stibogluconate, in the treatment of cutaneous leishmaniasis

It would be very useful to have a more effective and more rapid method available for the treatment of cutaneous leishmaniasis (CL). The main aim of the present, Iranian study, was to see if the combination of cryotherapy and intralesional injections with meglumine antimoniate (C + MA) would be more effective than the injections given alone (MA) or the combination of cryotherapy plus intralesional sodium stibogluconate (C + SS). Forty patients (with 67 lesions) were treated with C + MA, another 40 (with 65 lesions) were treated with C + SS and 100 patients (with 180 lesions) were treated with MA. Follow-up for 6 months after the final treatment indicated that 89.5% of the lesions treated with C + MA, 92.3% of those treated with C + SS but only 50% of the lesions treated with MA only were completely cured. The frequencies of cure in the two cryotherapy groups were similar, both being significantly higher than that in the MA group (P < 0.05). The combination of cryotherapy with intralesional injections of meglumine antimoniate or sodium stibogluconate, which is much more effective than the use of intralesional meglumine antimoniate alone, should be promoted.

[Cutaneous leishmaniasis]

Leishmaniasis is a vector-borne disease caused by an obligate intracellular protozoa, Leishmania, which resides in macrophages. The parasite is transmitted by an infected female sandfly. The incidence of cutaneous leishmaniasis approaches 2 million new cases per year with 90% of the cases occurring in the "Old World", while the "New World" accounts for the rest. Infection may be restricted to the skin with development of characteristic ulcers, or may affect the mucous membranes in its mucocutaneous form. The clinical diagnosis is verified by the presence of amastigotes in slit-skin smears. Therapeutic modalities include systemic treatments such as the pentavalent antimony compound sodium stibogluconate, liposomal formulations of amphotericin B, oral ketoconazole or itraconazole, as well as topical paromomycin sulphate, local heat, freezing with liquid nitrogen, or photodynamic therapy. An effective vaccine is not available.

Therapy of cutaneous leishmaniasis

There have been many treatment modalities used for the therapy of cutaneous leishmaniasis. Although treatment need not be given for cosmetically insignificant lesions, which are often self-limited, therapy is usually indicated for larger, cosmetically significant and disfiguring lesions, and lesions which progress. This review summarizes the published evidence in support of the numerous therapeutic options that have been employed for cutaneous leishmaniasis.

Leishmaniasis: recognition and management with a focus on the immunocompromised patient

Leishmaniasis is a protozoan disease whose clinical manifestations depend both on the infecting species of Leishmania and the immune response of the host. Transmission of the disease occurs by the bite of a sandfly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis (CL), to the mucous membranes in mucosal leishmaniasis or spread internally in visceral leishmaniasis (VL). In the last 2 decades, leishmaniasis, especially VL, has been recognized as an opportunistic disease in immunocompromised patients, particularly those infected with HIV. Leishmaniasis is characterized by a spectrum of disease phenotypes that correspond to the strength of the host's cell-mediated immune response. Both susceptible and resistant phenotypes exist within human populations. Clinical cutaneous disease ranges from a few spontaneously-healing lesions, to diffuse external or internal disease, to severe mucous membrane involvement. Spontaneously-healing lesions are associated with positive antigen-specific T cell responsiveness, diffuse cutaneous and visceral disease with T cell non-responsiveness, and mucocutaneous disease with T cell hyperresponsiveness. Current research is focused on determining the extent to which this spectrum of host response is genetically determined. In endemic areas, diagnosis is often made on clinical grounds alone including: small number of lesions; on exposed areas; present for a number of months; resistant to all types of attempted treatments; and usually no pain or itching. Multiple diagnostic techniques are available. When evaluating treatment, the natural history of leishmaniasis must be considered. Lesions of CL heal spontaneously over 1 month to 3 years, while lesions of mucocutaneous and VL rarely, if ever, heal without treatment. Consequently, all the latter patients require treatment. Therapy is not always essential in localized CL, although the majority of such patients are treated. Patients with lesions on the face or other cosmetically important areas are treated to reduce the size of the resultant scar. In addition, the species of parasite should be identified so that infection with Leishmania braziliensis and Leishmania panamensis can be treated to reduce the risk of development of mucocutaneous disease. Treating patients with Leishmania and HIV co-infection requires close monitoring for effectiveness of treatment, especially because of the high relapse rates. Proven treatments include: antimonials, pentamidine, amphotericin B, interferon with antimony. Treatments where current clinical experience is too limited include: allopurinol, ketoconazole, itraconazole, immunotherapy, rifampin, dapsone, localized heat, paromomycin ointment and cryotherapy. Investigational treatments include: WR6026, liposomal amphotericin and miltefosine. In addition, vaccines for leishmaniasis are being investigated in clinical trials.

Leishmaniasis as an emerging infection

Leishmaniasis is a protozoan disease whose diverse clinical manifestations are dependent both on the infecting species of Leishmania and the immune response of the host. Transmission of the disease occurs by the bite of a sand fly infected with Leishmania parasites. Infection may be restricted to the skin in cutaneous leishmaniasis, limited to the mucous membranes in mucosal leishmaniasis, or spread internally in visceral leishmaniasis or kala azar. The overall prevalence of leishmaniasis is 12 million cases worldwide, and the global yearly incidence of all clinical forms approaches 2 million new cases (World Health Organization WHO/ LEISH/200.42, Leishmania/HIV Co-Infection in Southwestern Europe 1990-98: Retrospective Analysis of 965 Cases, 2000). In the last two decades, leishmaniasis, especially visceral leishmaniasis, has been recognized as an opportunistic disease in the immunocompromised, particularly in patients infected with human immunodeficiency virus.

1. Cutaneous leishmaniasis

Cutaneous leishmaniasis (CL) in Sudan is caused by Leishmania major, zymodeme LON-1. The disease is endemic in many parts of the country. The vector is Phlebotomus papatasi and the animal reservoir is probably the Nile rat Arvicanthis niloticus. Clinically, patients usually present with papules, nodules, or nodulo-ulcerative lesions, mainly on the exposed parts of the skin. In 20% of cases the parasite disseminates through the lymphatics, producing sporotrichoid-like lesions. The pathology of the lesion is described. Langerhans cells are the main antigen-presenting cells in CL. They pickup antigen from the dermis and migrate to regional lymph nodes where they present it to T cells. Antigen-specific activated T cells home to the dermis where they stimulate macrophages to eliminate the parasite. Peripheral blood mononuclear cells (PBMC) proliferate in response to Leishmania antigen in vitro and produce cytokines. PBMC of patients with mild and severe disease produce Th1- and Th2-like cytokine patterns, respectively. The criteria for the clinical diagnosis of CL are described. The diagnosis is confirmed by the demonstration of parasites in slit smears in 50-70% of cases and in histological sections in 70%. With primers specific for L. major, the polymerase chain reaction is positive in 86% of cases. Since CL is a self-limiting disease, treatment is confined to patients with severe disease.

Cutaneous leishmaniasis

The incidence of leishmaniasis is increasing globally due to population and environmental changes. Ease of worldwide travel and immigrant populations means that the UK surgeon is more likely to encounter cutaneous lesions. Two cases are presented and treatment options discussed.

Zinc sulphate in the treatment of cutaneous leishmaniasis: an in vitro and animal study

This study was designed to evaluate the effectiveness of zinc sulphate both in vitro and in an animal model against both strains of old world cutaneous leishmaniasis. The in vitro sensitivities of promastigotes and axenic amastigotes of both Leishmania major and L. tropica to zinc sulphate was determined, the LD50 calculated and compared to the standard treatment for cutaneous leishmaniasis pentavalent antimony compounds. The results show that the two forms of both strains were sensitive to zinc sulphate and their respective LD50 were lower compared to the pentavalent antimony compound. Furthermore the sensitivities of the forms of both strains were tested using a simple slide method and compared to results of the standard method. To confirm this result, zinc sulphate was administered orally to mice infected with cutaneous leishmaniasis both therapeutically and prophylactically. Results showed that oral zinc sulphate was effective in both treatment and prophylaxis for cutaneous leishmaniasis. These results encourage the use of oral zinc sulphate in the treatment of cutaneous leishmaniasis clinically.