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Sridharan K, Sivaramakrishnan G. Comparative assessment of interventions for treating cutaneous leishmaniasis: A network meta-analysis of randomized clinical trials. Acta Trop 2021; 220:105944. [PMID: 33957088 DOI: 10.1016/j.actatropica.2021.105944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/28/2021] [Accepted: 04/26/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Various interventions including laser therapy, heat therapy, and several drugs have been trialed in patients with cutaneous leishmaniasis. Due to the lack of an evidence-based comparison of all these interventions, we carried out the present network meta-analysis. METHODS Electronic databases were searched for randomized clinical trials evaluating the efficacy and safety of any interventions in patients with cutaneous leishmaniasis. The proportion of patients with complete cure was the primary outcome. The proportion of lesions cured at the end of treatment, the proportion of lesions with minimal/no response to treatment, and proportion of wounds with minimal/no change were the secondary outcomes. Random-effects modeling was used for generating pooled estimates. Rankogram plot was used for identifying the 'best intervention'. For interventions containing a combination of treatments, backslash (/) has been used for depicting the same. RESULTS One-hundred and thirty-one studies were included. Intralesional meglumine, topical paromomycin/gentamicin, topical paromomycin, parenteral sodium stibogluconate, topical honey/intralesional meglumine, topical liposomal amphotericin B, oral zinc sulphate, oral miltefosine, parenteral meglumine, heat therapy, topical liposomal azithromycin, intralesional meglumine/silver dressing, intralesional sodium stibogluconate, parenteral meglumine/intralesional meglumine, oral allopurinol/parenteral meglumine, topical trichloroacetic acid/heat therapy, oral zinc sulphate/oral ketoconazole, topical imiquimod/cryotherapy, intralesional meglumine/cryotherapy, topical herbal extract of Z-HE, parenteral pentamidine, topical trichloroacetic acid/intralesional meglumine, carbon-dioxide laser, topical recombinant granulocyte-macrophage colony-stimulating factor/parenteral meglumine, intralesional dapsone, carbon-dioxide laser/intralesional meglumine, moist wet dressing with sodium hypochlorite, parenteral sodium stibogluconate/intralesional recombinant granulocyte-macrophage colony-stimulating factor, oral dapsone, intralesional sodium stibogluconate/oral ketoconazole, intralesional sodium stibogluconate/parenteral sodium stibogluconate and electrocautery/moist wet dressing with sodium hypochlorite were observed with significantly greater proportion of patients with complete cure compared to placebo/untreated controls. Rankogram analysis revealed that parenteral pentamidine has the highest statistical probability of being the best in the pool. CONCLUSION We observed several interventions to be effective for treating cutaneous leishmaniasis. However, greater caution is required in interpreting the results as the estimates are likely to change with the advent of results from future studies.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.
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Iraji F, Asilian A, Heidari A, Shariat S, Bokaie Jazi S, Siadat AH. Combination of continuous wave CO
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laser and topical application of trichloroacetic acid 50% vs CO
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laser alone the treatment of cutaneous leishmaniasis (A case series of 6 patients). J Cosmet Dermatol 2019; 19:1367-1370. [DOI: 10.1111/jocd.13181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 03/27/2019] [Accepted: 04/22/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Fariba Iraji
- Skin Diseases and Leishmaniasis Research Center Department of Dermatology Isfahan University of Medical Sciences Isfahan Iran
| | - Ali Asilian
- Skin Diseases and Leishmaniasis Research Center Department of Dermatology Isfahan University of Medical Sciences Isfahan Iran
| | - Asieh Heidari
- Skin Diseases and Leishmaniasis Research Center Department of Dermatology Isfahan University of Medical Sciences Isfahan Iran
- Skin Diseases and Leishmaniasis Research Center Isfahan University of Medical Sciences Isfahan Iran
| | - Sheila Shariat
- Skin Diseases and Leishmaniasis Research Center Department of Dermatology Isfahan University of Medical Sciences Isfahan Iran
| | - Safura Bokaie Jazi
- Skin Diseases and Leishmaniasis Research Center Isfahan University of Medical Sciences Isfahan Iran
- School of Pharmacy Isfahan university of Medical Sciences Isfahan Iran
| | - Amir Hossein Siadat
- Skin Diseases and Leishmaniasis Research Center Isfahan University of Medical Sciences Isfahan Iran
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Bilgic-Temel A, Murrell DF, Uzun S. Cutaneous leishmaniasis: A neglected disfiguring disease for women. Int J Womens Dermatol 2019; 5:158-165. [PMID: 31360749 PMCID: PMC6637076 DOI: 10.1016/j.ijwd.2019.01.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/09/2019] [Accepted: 01/17/2019] [Indexed: 12/16/2022] Open
Abstract
Leishmaniasis is one of eight neglected tropical diseases currently endemic in 102 countries/areas around the world. In recent years, cutaneous leishmaniasis (CL) has been increasingly observed among migrants, travelers, ecotourists, and military personnel. Because of its great capacity to mimic other dermatoses, CL is one of the great imitators and can mislead practitioners, which can result in untreated lesions that cause scars. CL is a disfiguring disease, especially for women, and often leaves scars on visible body sites, causing psychological, social, and economic problems. CS is a challenge, especially in nonendemic regions, such as Australia, because experience with diagnosis and management of the disease is limited.
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Affiliation(s)
- Asli Bilgic-Temel
- St. George Hospital, Department of Dermatology, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Dedee F. Murrell
- St. George Hospital, Department of Dermatology, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Soner Uzun
- Department of Dermatology and Venereology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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Heras‐Mosteiro J, Monge‐Maillo B, Pinart M, Lopez Pereira P, Reveiz L, Garcia‐Carrasco E, Campuzano Cuadrado P, Royuela A, Mendez Roman I, López‐Vélez R. Interventions for Old World cutaneous leishmaniasis. Cochrane Database Syst Rev 2017; 12:CD005067. [PMID: 29192424 PMCID: PMC6485999 DOI: 10.1002/14651858.cd005067.pub5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Julio Heras‐Mosteiro
- Rey Juan Carlos UniversityDepartment of Preventive Medicine and Public Health & Immunology and MicrobiologyAvda. Atenas s/nAlcorcónMadridSpain28922
- Ramón y Cajal University HospitalDepartment of Preventive Medicine and Public HealthMadridSpain
| | - Begoña Monge‐Maillo
- Ramón y Cajal University HospitalTropical Medicine & Clinical Parasitology, Infectious Diseases DepartmentCarretera de Colmenar Viejo km. 9,100MadridSpain28034
| | - Mariona Pinart
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UKNottinghamUK
| | - Patricia Lopez Pereira
- Ramón y Cajal University HospitalDepartment of Preventive Medicine and Public HealthMadridSpain
| | | | - Emely Garcia‐Carrasco
- National Referral Centre for Tropical DiseasesInfectious Diseases DepartmentCtra Colmenar, Km 9,100.MadridSpain28034
| | - Pedro Campuzano Cuadrado
- Rey Juan Carlos UniversityDepartment of Preventive Medicine and Public Health & Immunology and MicrobiologyAvda. Atenas s/nAlcorcónMadridSpain28922
| | - Ana Royuela
- Biomedical Sciences Research Institute,Hospital Universitario Puerta de Hierro‐MajadahondaDepartment of BiostatisticsMajadahondaSpain28222
| | - Irene Mendez Roman
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamSpainNG7 2NR
| | - Rogelio López‐Vélez
- Ramón y Cajal University HospitalTropical Medicine & Clinical Parasitology, Infectious Diseases DepartmentCarretera de Colmenar Viejo km. 9,100MadridSpain28034
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Heras‐Mosteiro J, Monge‐Maillo B, Pinart M, Lopez Pereira P, Garcia‐Carrasco E, Campuzano Cuadrado P, Royuela A, Mendez Roman I, López‐Vélez R. Interventions for Old World cutaneous leishmaniasis. Cochrane Database Syst Rev 2017; 11:CD005067. [PMID: 29149474 PMCID: PMC6486265 DOI: 10.1002/14651858.cd005067.pub4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
| | - Begoña Monge‐Maillo
- Ramón y Cajal University HospitalTropical Medicine & Clinical Parasitology, Infectious Diseases DepartmentCarretera de Colmenar Viejo km. 9,100MadridSpain28034
| | - Mariona Pinart
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UKNottinghamUK
| | - Patricia Lopez Pereira
- Ramón y Cajal University HospitalDepartment of Preventive Medicine and Public HealthMadridSpain
| | - Emely Garcia‐Carrasco
- National Referral Centre for Tropical DiseasesInfectious Diseases DepartmentCtra Colmenar, Km 9,100.MadridSpain28034
| | - Pedro Campuzano Cuadrado
- Rey Juan Carlos UniversityDepartment of Preventive Medicine and Public Health & Immunology and MicrobiologyAvda. Atenas s/nAlcorcónMadridSpain28922
| | - Ana Royuela
- Biomedical Sciences Research Institute,Hospital Universitario Puerta de Hierro‐MajadahondaDepartment of BiostatisticsMajadahondaSpain28222
| | - Irene Mendez Roman
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamSpainNG7 2NR
| | - Rogelio López‐Vélez
- Ramón y Cajal University HospitalTropical Medicine & Clinical Parasitology, Infectious Diseases DepartmentCarretera de Colmenar Viejo km. 9,100MadridSpain28034
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Galvão EL, Rabello A, Cota GF. Efficacy of azole therapy for tegumentary leishmaniasis: A systematic review and meta-analysis. PLoS One 2017; 12:e0186117. [PMID: 29016694 PMCID: PMC5633178 DOI: 10.1371/journal.pone.0186117] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/25/2017] [Indexed: 11/18/2022] Open
Abstract
Background Several controlled and uncontrolled studies addressing azole antifungal drugs for cutaneous and mucosal leishmaniasis have been published with inconclusive results. We conducted a systematic literature review of studies evaluating the efficacy and toxicity associated with azole therapy for tegumentary leishmaniasis. Methodology PRISMA guidelines for systematic reviews and the Cochrane manual were followed, and the review methodology was registered (PROSPERO; CRD42016048668). Sources included the EMBASE, Web of Science, MEDLINE, LILACS, and IBECS databases along with a manual search of references from evaluated studies. Additional resources such as Google Scholar and clinicaltrials.gov were also searched. We included all studies reporting cure rate after cutaneous or mucosal leishmaniasis treatment with systemic azole drugs, regardless of their design. R software was used to estimate global rates of success and adverse events with each drug. The main outcome of interest was clinical cure, defined as complete re-epithelialization of all lesions. Results A total of 37 studies involving 1259 patients that reported outcomes after fluconazole (9), ketoconazole (14) and itraconazole (15) treatments were included. Only 14 (38%) were randomized controlled trials (RCT). The pooled azole final efficacy rate was 64% (CI95%: 57–70%) for all studies and 60% (CI95%: 50–70%) (p = 0.41) if only RCTs studies were considered. Twenty-four studies were conducted in the Old World and 13 studies in the Americas. The final efficacy rate according to New and Old World were 62% (CI95%: 43–77%) and 66% (CI95%: 58–73%), respectively. The final efficacy rate of azoles according to species were 89% (CI95%: 50–98%) for L. mexicana; 88% for L. infantum (CI95%: 27–99%); 80% for L. donovani; 53% (CI95%: 29–76%) for L. major; 49% for L. braziliensis (CI95%: 21–78%); and 15% (CI95%: 1–84%) for L. tropica. The cure rates were similar among the fluconazole, ketoconazole and itraconazole group arms (p = 0.89), specifically 61% (CI95%: 48–72%), 64% (CI95%: 44–80%) 65% (CI95%: 56–72%), respectively. Adverse events during fluconazole, itraconazole and ketoconazole therapy were reported in 7% (CI95%: 3–14%), 12% (CI95% 8–19%) and 13% (CI95%: 6–29%) of treated patients, respectively, without difference among them (p = 0.35). This systematic review included studies with small samples and both non-comparative and non-randomized studies and the main limitation was the low quality of the available studies. Conclusions Available evidence suggests that fluconazole, ketoconazole and itraconazole have similar and modest efficacy rates for tegumentary leishmaniasis treatment. There is insufficient evidence to support the exclusive use of azole therapy as a single agent for leishmaniasis treatment.
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Affiliation(s)
- Endi Lanza Galvão
- Pesquisa Clínica e Políticas Públicas em Doenças Infecto-Parasitárias–Centro de Pesquisas René Rachou—Fundação Oswaldo Cruz, Fiocruz, Belo Horizonte, Minas Gerais, Brazil
- * E-mail:
| | - Ana Rabello
- Pesquisa Clínica e Políticas Públicas em Doenças Infecto-Parasitárias–Centro de Pesquisas René Rachou—Fundação Oswaldo Cruz, Fiocruz, Belo Horizonte, Minas Gerais, Brazil
| | - Gláucia Fernandes Cota
- Pesquisa Clínica e Políticas Públicas em Doenças Infecto-Parasitárias–Centro de Pesquisas René Rachou—Fundação Oswaldo Cruz, Fiocruz, Belo Horizonte, Minas Gerais, Brazil
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Emami S, Tavangar P, Keighobadi M. An overview of azoles targeting sterol 14α-demethylase for antileishmanial therapy. Eur J Med Chem 2017; 135:241-259. [PMID: 28456033 DOI: 10.1016/j.ejmech.2017.04.044] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/11/2017] [Accepted: 04/18/2017] [Indexed: 02/07/2023]
Abstract
The azole antifungal drugs are an important class of chemotherapeutic agents with broad-spectrum of activity against yeasts and filamentous fungi, act in the ergosterol biosynthetic pathway through inhibition of the cytochrome P450-dependent enzyme sterol 14α-demethylase. Azole antifungals have also been repurposed for treatment of tropical protozoan infections including human leishmaniasis. Recent advances in molecular biology and computational chemistry areas have increased our knowledge about sterol biochemical pathway in Leishmania parasites. Based on the importance of sterol biosynthetic pathway in Leishmania parasites, we reviewed all studies reported on azoles for potential antileishmanial therapy along their structural and biological aspects. This review may help medicinal chemists for design of new azole-derived antileishmanial drugs.
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Affiliation(s)
- Saeed Emami
- Department of Medicinal Chemistry and Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran.
| | - Pegah Tavangar
- Department of Medicinal Chemistry and Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Masoud Keighobadi
- Student Research Committee, Pharmaceutical Sciences Research Center, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
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Zakai HA, Zimmo SK. Effects of itraconazole and terbinafine onLeishmania majorlesions in BALB/c mice. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 2016. [DOI: 10.1080/00034983.2000.11813603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Balai M, Gupta LK, Khare AK, Srivastava A, Mittal A, Singh A. Cutaneous Leishmaniasis in a Nonendemic Area of South Rajasthan: A Prospective Study. Indian J Dermatol 2016; 61:521-4. [PMID: 27688441 PMCID: PMC5029237 DOI: 10.4103/0019-5154.190117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Cutaneous leishmaniasis (CL) usually occurs in areas with hot and dry climate. In India, the desert areas of Rajasthan, Gujarat, and the plains of Northwestern frontier are endemic for this disorder. AIMS AND OBJECTIVES The present study was aimed to describe clinicoepidemiological profile of the cases of CL from South Rajasthan, which is a nonendemic area of Rajasthan. MATERIALS AND METHODS During a period of 4 years (2010-2014), a total of 23 patients with CL were diagnosed. All the suspected cases of CL were interrogated in detail regarding visit to areas where CL is known to occur. This was followed by clinical examination, relevant investigations, and treatment. All except one patient were treated with azole antifungals. In one patient, CO2 laser ablation was done. RESULTS There were 12 (52.17%) males and 11 (47.83%) females with age ranging from 3 to 72 years. Duration of disease ranged from 7 days to 10 months. Face (15; 65.22%) and extremities (12; 52.17%) were involved in majority of the patients. Common morphologies were noduloulcerative lesions and crusted plaques. Tissue smear for Leishmania donovani bodies was positive in all except one patient. CONCLUSION The present report highlights occurrence of CL in nonendemic area. Further epidemiological studies are required for identification of vector and strain of Leishmania involved.
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Affiliation(s)
- Manisha Balai
- Department of Dermatology, Venereology and Leprology, RNT Medical College, Udaipur, Rajasthan, India
| | - Lalit Kumar Gupta
- Department of Dermatology, Venereology and Leprology, RNT Medical College, Udaipur, Rajasthan, India
| | - Ashok Kumar Khare
- Department of Dermatology, Venereology and Leprology, RNT Medical College, Udaipur, Rajasthan, India
| | - Ankita Srivastava
- Department of Dermatology, Venereology and Leprology, RNT Medical College, Udaipur, Rajasthan, India
| | - Asit Mittal
- Department of Dermatology, Venereology and Leprology, RNT Medical College, Udaipur, Rajasthan, India
| | - Ajit Singh
- Department of Dermatology, Venereology and Leprology, RNT Medical College, Udaipur, Rajasthan, India
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Vakil NH, Fujinami N, Shah PJ. Pharmacotherapy for Leishmaniasis in the United States: Focus on Miltefosine. Pharmacotherapy 2015; 35:536-45. [DOI: 10.1002/phar.1585] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Niyati H. Vakil
- Department of Pharmacy; Cedars-Sinai Medical Center; Los Angeles California
| | - Noriko Fujinami
- Department of Pharmacy; Cedars-Sinai Medical Center; Los Angeles California
| | - Punit J. Shah
- Department of Pharmacy; Alexian Brothers Health System; Elk Grove Village Illinois
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Species-directed therapy for leishmaniasis in returning travellers: a comprehensive guide. PLoS Negl Trop Dis 2014; 8:e2832. [PMID: 24787001 PMCID: PMC4006727 DOI: 10.1371/journal.pntd.0002832] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 03/14/2014] [Indexed: 02/06/2023] Open
Abstract
Background Leishmaniasis is increasingly reported among travellers. Leishmania species vary in sensitivity to available therapies. Fast and reliable molecular techniques have made species-directed treatment feasible. Many treatment trials have been designed poorly, thus developing evidence-based guidelines for species-directed treatment is difficult. Published guidelines on leishmaniasis in travellers do not aim to be comprehensive or do not quantify overall treatment success for available therapies. We aimed at providing comprehensive species-directed treatment guidelines. Methodology/Principal Findings English literature was searched using PubMed. Trials and observational studies were included if all cases were parasitologically confirmed, the Leishmania species was known, clear clinical end-points and time points for evaluation of treatment success were defined, duration of follow-up was adequate and loss to follow-up was acceptable. The proportion of successful treatment responses was pooled using mixed effects methods to estimate the efficacy of specific therapies. Final ranking of treatment options was done by an expert panel based on pooled efficacy estimates and practical considerations. 168 studies were included, with 287 treatment arms. Based on Leishmania species, symptoms and geography, 25 clinical categories were defined and therapy options ranked. In 12/25 categories, proposed treatment agreed with highest efficacy data from literature. For 5/25 categories no literature was found, and in 8/25 categories treatment advise differed from literature evidence. For uncomplicated cutaneous leishmaniasis, combination of intralesional antimony with cryotherapy is advised, except for L. guyanensis and L. braziliensis infections, for which systemic treatment is preferred. Treatment of complicated (muco)cutaneous leishmaniasis differs per species. For visceral leishmaniasis, liposomal amphotericin B is treatment of choice. Conclusions/Significance Our study highlights current knowledge about species-directed therapy of leishmaniasis in returning travellers and also demonstrates lack of evidence for treatment of several clinical categories. New data can easily be incorporated in the presented overview. Updates will be of use for clinical decision making and for defining further research. Human leishmaniasis is caused by unicellular parasites that are injected into the skin by sand-flies, small, flying insects. Many different Leishmania species cause various manifestations of disease, both of the skin and internal organs. Leishmaniasis is a curable disease but clear guidelines on the best available treatment are lacking. Leishmania species differ in sensitivity to available drugs. Until recently, identification of the infecting Leishmania parasite was laborious, thus therapy could not precisely be targeted to the infecting species, in contrast to many other infectious diseases. Nowadays, Leishmania parasites can be identified relatively easily with new DNA techniques. We studied efficacy of therapies for diseases due to different Leishmania species, limited to the English literature. Efficacy was summarized and presented in an easy to read format. Because of difficulties with identification of parasite species in earlier studies, quality of evidence was often limited. Our findings are a major help for clinicians to easily find optimal treatment for specific patients. Moreover, our results demonstrate where additional research is needed to further improve treatment of leishmaniasis.
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Masmoudi A, Hariz W, Marrekchi S, Amouri M, Turki H. Old World cutaneous leishmaniasis: diagnosis and treatment. J Dermatol Case Rep 2013; 7:31-41. [PMID: 23858338 DOI: 10.3315/jdcr.2013.1135] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 04/10/2013] [Indexed: 11/11/2022]
Abstract
Cutaneous leishmaniasis is a major world health problem. Diagnosis is suspected on evocative clinical presentation in patients living in or coming from endemic areas. Several methods have been used. The smear is a simple investigation used in endemic regions. The culture enables to identify the specimen. PCR has a high sensitivity. Montenegro's reaction is used in the epidemiological study. Pentavalent antimony derivatives remain the mainstay of systemic treatment. Their efficiency is well established. Their toxicity should be researched. Other treatments can be utilized, such as miltefosine. Local therapy is used in uncomplicated lesions. Injections of the pentavalent antimony derivate, cryotherapy and paromomycin ointmentsis are important options and should be used more frequently in Old World leishmaniasis.
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Hua X, Zhang R, Yang H, Lei S, Zhang Y, Ran Y. Primary oral Penicillium marneffei infection diagnosed by PCR-based molecular identification and transmission electron microscopic observation from formalin-fixed paraffin-embedded tissues. Med Mycol Case Rep 2012; 2:15-8. [PMID: 24432206 DOI: 10.1016/j.mmcr.2012.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 10/20/2012] [Accepted: 10/28/2012] [Indexed: 02/05/2023] Open
Abstract
We report a case of primary oral Penicillium marneffei infection in a 39-year-old man without HIV infection. Although fungal culture was negative, the patient was finally confirmed to have P. marneffei infection by PCR-based molecular identification and transmission electron microscopic observation from formalin-fixed, paraffin-embedded tissues. The patient was cured with taking itraconazole for 3 months.
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Affiliation(s)
- Xia Hua
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ruifeng Zhang
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hanjun Yang
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Song Lei
- Department of Pathology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yizhi Zhang
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yuping Ran
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu 610041, China
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Al-Mutairi N, Alshiltawy M, El Khalawany M, Joshi A, Eassa BI, Manchanda Y, Gomaa S, Darwish I, Rijhwani M. Tropical medicine rounds: Treatment of Old World cutaneous leishmaniasis with dapsone, itraconazole, cryotherapy, and imiquimod, alone and in combination. Int J Dermatol 2009; 48:862-9. [PMID: 19673049 DOI: 10.1111/j.1365-4632.2008.04010.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Nawaf Al-Mutairi
- Department of Dermatology, Institutional Affiliation, Farwaniya Hospital, Kuwait.
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Siddiqui M, Ai-Mofadhi A, Ai-Reshaid A, Ai-Rakban A, Ai-Jarba A, Kahtani H, Aziz IA, Johani HAI. Treatment of cutaneous leishmaniasis with itraconazole. J DERMATOL TREAT 2009. [DOI: 10.3109/09546639809160701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
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.
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Affiliation(s)
- Urbà González
- Department of Dermatology, Research Unit for Evidence-based Dermatology, Hospital Plató, c/ Plato 21, Barcelona, Catalunya, Spain, 08006.
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Tuon FF, Amato VS, Graf ME, Siqueira AM, Nicodemo AC, Neto VA. Treatment of New World cutaneous leishmaniasis - a systematic review with a meta-analysis. Int J Dermatol 2008; 47:109-24. [DOI: 10.1111/j.1365-4632.2008.03417.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
A leishmaniose tegumentar americana é doença infecciosa da pele e mucosa, cujo agente etiológico é um protozoário do gênero Leishmania. Seu tratamento é desafio porque as drogas disponíveis apresentam elevada toxicidade, e nenhuma delas é bastante eficaz. A recidiva, a falha terapêutica em pacientes imunodeprimidos e a resistência ao tratamento são fatores que motivam a busca de uma droga ideal.
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Khatami A, Firooz A, Gorouhi F, Dowlati Y. Treatment of acute Old World cutaneous leishmaniasis: a systematic review of the randomized controlled trials. J Am Acad Dermatol 2007; 57:335.e1-29. [PMID: 17337090 DOI: 10.1016/j.jaad.2007.01.016] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2006] [Revised: 12/28/2006] [Accepted: 01/09/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cutaneous leishmaniasis (CL) is caused by different species of Leishmania and transmitted by the bite of infected sand flies. It is a health problem in many countries. OBJECTIVE This study was performed to assess the evidence for the efficacy of different therapeutic modalities for acute Old World CL, which is usually caused by L major and L tropica. METHODS Evidence was reviewed according to the hierarchy of evidence. Because there have been no published systematic reviews on this topic to date, the primary source of evidence was individual randomized controlled trials (RCTs). Multiple databases were systematically searched. Using independent double review and published quality review criteria, articles were rated as good, fair, or poor. Treatment benefit data were tabulated, and conclusions were based on the rated strength of published evidence. RESULTS In all, 50 RCTs met inclusion criteria consisting of 5515 patients in 119 study arms. Reviewed trials were highly variable in quality and methods and generally provide weak evidence for treatment of acute Old World CL. LIMITATIONS The quality of included studies was generally poor. CONCLUSIONS Well-designed randomized, double-blind, controlled trials should be designed and conducted to find better evidence for the treatment of acute Old World CL.
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Affiliation(s)
- Alireza Khatami
- Center for Research and Training in Skin Diseases and Leprosy, Tehran University of Medical Sciences, Iran
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21
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Abstract
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.
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Nassiri-Kashani M, Firooz A, Khamesipour A, Mojtahed F, Nilforoushzadeh M, Hejazi H, Bouzari N, Dowlati Y. A randomized, double-blind, placebo-controlled clinical trial of itraconazole in the treatment of cutaneous leishmaniasis. J Eur Acad Dermatol Venereol 2005; 19:80-3. [PMID: 15649196 DOI: 10.1111/j.1468-3083.2004.01133.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Several modalities have been used for the treatment of cutaneous leishmaniasis (CL) with various results. In vitro and in vivo studies have shown inhibitory effects of azole drugs on Leishmania parasites. OBJECTIVES To evaluate the efficacy and tolerability of oral itraconazole in the treatment of CL caused by L. major. METHODS A total of 200 patients with parasitologically confirmed CL with a duration of less than 45 days from a well known L. major endemic area were included in a randomized, double-blind, placebo-controlled clinical trial. The patients received either itraconazole 200 mg daily (100 patients) or placebo (100 patients) for 8 weeks. The primary outcome measures were clinical cure (complete re-epithelization of all lesions) and parasitological cure at the end of the treatment. RESULTS Eighty-three patients in the itraconazole and 75 patients in the placebo group completed the treatment course. After 8 weeks of treatment, clinical cure was observed in 59% and 53% and parasitological cure was observed in 83% and 76% of patients in the itraconazole and placebo groups, respectively, which were not significantly different. There was no difference in the rate of adverse events. CONCLUSIONS An 8-week course of oral itraconazole was not more effective than placebo in the treatment of CL.
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Affiliation(s)
- M Nassiri-Kashani
- Center for Research & Training in Skin Diseases & Leprosy, Tehran University of Medical Sciences, Tehran, Iran
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Al-Tawfiq JA, AbuKhamsin A. Cutaneous leishmaniasis: a 46-year study of the epidemiology and clinical features in Saudi Arabia (1956-2002). Int J Infect Dis 2004; 8:244-50. [PMID: 15234329 DOI: 10.1016/j.ijid.2003.10.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2003] [Revised: 10/25/2003] [Accepted: 10/27/2003] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the epidemiology of cutaneous leishmaniasis in the Eastern Province of Saudi Arabia. In addition, the clinical spectrum of the disease was evaluated. METHODS This is a retrospective study of cutaneous leishmania cases from 1956 to 2002. RESULTS In the study period, there were 1862 patients with cutaneous leishmaniasis in the Saudi Aramco health care system. The disease is more prevalent in the Al-Hasa Oasis (Eastern Province of Saudi Arabia) and affects males and females equally. Cutaneous leishmaniasis follows a seasonal distribution in parallel with the known activity of the sandfly. The majority (76%) of cases occurred in patients < 15 years of age and the disease affected the extremities more frequently than the face. Seventy-one percent of patients presented with a single lesion and 27% presented with two lesions. Ulcerative cutaneous leishmaniasis was the predominant morphology (89%). CONCLUSION Cutaneous leishmaniasis attained epidemic proportions in 1973 and subsequently declined and reached a plateau in the mid-1980s. Skin involvement is the major clinical picture, with no evidence of dissemination or viscerotropic syndrome.
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Affiliation(s)
- Jaffar A Al-Tawfiq
- Division of Internal Medicine Specialty Services, P.O. Box 76, Rm A-420, Building 61, Dhahran Health Center, Saudi Aramco, Dhahran 31311, Saudi Arabia.
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Abstract
Current dosing regimens for itraconazole are effective, safe, and versatile for use in superficial fungal infections in children, particularly tinea capitis. Good efficacy rates have been noted in both Trichophyton and Microsporum tinea capitis infections. Itraconazole has a high affinity for keratin, and accumulates to high levels at the site of superficial fungal infections. A pulse regimen may be chosen over continuous dosing, because the accumulation persists after dosing of itraconazole has been stopped. An oral solution of itraconazole is available, and may be more convenient for children who cannot swallow capsules. The oral solution also produces good rates of efficacy, but may be associated with a somewhat higher potential for gastrointestinal adverse events than the capsules. The range of adverse events noted with itraconazole capsules or oral solution use in children is similar to the range in adults. Events are generally mild and transient. Attention must be taken to note any medications that the child is using, because itraconazole is associated with a range of potential drug interactions. This safety of use, in combination with itraconazole's wide antifungal spectrum and pharmacokinetic properties, which allow for shorter dosing regimens, may make itraconazole a suitable alternative to griseofulvin for pediatric superficial fungal infections.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, Sunnybrook and Women's College Health Science Center (Sunnybrook Site), University of Toronto, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada.
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Abstract
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.
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Affiliation(s)
- Samuel A Lee
- Infectious Diseases Section, VA Connecticut Healthcare System, West Haven, CT 06516, USA.
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Momeni AZ, Aminjavaheri M, Omidghaemi MR. Treatment of cutaneous leishmaniasis with ketoconazole cream. J DERMATOL TREAT 2003; 14:26-9. [PMID: 12745852 DOI: 10.1080/09546630305552] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cutaneous leishmaniasis (CL) is endemic in many countries. It has been recognized as a major public health problem in Iran. Many drugs have been suggested for the treatment of CL but most of them used intramuscularly or intravenously. Recently, a ketoconazole tablet has been used for the treatment of CL. OBJECTIVE To compare the efficacy of ketoconazole cream with placebo in the treatment of CL. METHODS The study was a double-blind, placebo-controlled trial. Patients with proven CL were treated with ketoconazole cream or placebo cream. The duration of treatment was 21 days and the patients were visited on days 7, 14 and 21. Follow-up was for 1 month after the end of treatment. RESULTS The study was completed in 73 patients (45 male, 28 female). The mean age of the patients was 19.9 years. A total of 38 patients received ketoconazole and 35 patients were treated with the placebo cream. At the end of treatment (day 21), complete healing had occurred in 15.7% of the ketoconazole group in comparison with 14.3% of the patients who were treated with the placebo cream (p=0.86). One month after the end of treatment the lesions in 28.9% of the ketoconazole group and 22.8% of the placebo group were healed (p=0.55). CONCLUSION Although the ketoconazole tablet has been reported to be effective in the treatment of some cases of CL, the low response rate in patients receiving ketoconazole cream indicates that it cannot be used as the single agent in the treatment of CL patients.
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Affiliation(s)
- A Z Momeni
- Isfahan University of Medical Sciences, PO Box 81465/1191, Isfahan, Iran.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Centre, Sehgal Nursing Home, Panchwati, Azadpur, Delhi, India.
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Alrajhi AA, Ibrahim EA, De Vol EB, Khairat M, Faris RM, Maguire JH. Fluconazole for the treatment of cutaneous leishmaniasis caused by Leishmania major. N Engl J Med 2002; 346:891-5. [PMID: 11907288 DOI: 10.1056/nejmoa011882] [Citation(s) in RCA: 199] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Whereas certain oral antifungal azoles are well documented to have activity against leishmania, data on the efficacy of fluconazole for leishmaniasis are limited. We conducted a controlled trial in Saudi Arabia of fluconazole for the treatment of cutaneous leishmaniasis caused by Leishmania major. METHODS This randomized, double-blind, placebo-controlled trial assessed the efficacy of oral fluconazole, in a dose of 200 mg daily for six weeks, in the treatment of parasitologically confirmed cutaneous leishmaniasis. The primary outcome measure was the time to the complete healing of all lesions. RESULTS A total of 106 patients were assigned to receive fluconazole, and 103 patients were assigned to receive placebo. Follow-up data were available for 80 and 65 patients, respectively. At the three-month follow-up, healing of lesions was complete for 63 of the 80 patients in the fluconazole group (79 percent) and 22 of the 65 patients in the placebo group (34 percent; relative risk of complete healing, 2.33 [95 percent confidence interval, 1.63 to 3.33]). According to an intention-to-treat analysis, the rates of healing were 59 percent and 22 percent, respectively (relative risk, 2.76 [95 percent confidence interval, 1.84 to 4.12]). Sodium stibogluconate was offered to 11 patients in the fluconazole group who returned for follow-up (14 percent) and 33 of those in the placebo group (51 percent) in whom oral treatment was judged to have failed. According to a Kaplan-Meier analysis, the time to healing was shorter for the fluconazole group (median, 8.5 weeks, as compared with 11.2 weeks in the placebo group; P<0.001 by the log-rank test). Side effects were mild and similar in both groups. CONCLUSIONS A six-week course of oral fluconazole is a safe and useful treatment for cutaneous leishmaniasis caused by L. major.
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Affiliation(s)
- Abdulrahman A Alrajhi
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Brigham and Women's Hospital, Boston, MA, USA
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Iqbal J, Hira PR, Saroj G, Philip R, Al-Ali F, Madda PJ, Sher A. Imported visceral leishmaniasis: diagnostic dilemmas and comparative analysis of three assays. J Clin Microbiol 2002; 40:475-9. [PMID: 11825959 PMCID: PMC153388 DOI: 10.1128/jcm.40.3.475-479.2001] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2001] [Revised: 09/17/2001] [Accepted: 11/09/2001] [Indexed: 11/20/2022] Open
Abstract
The present study evaluates the performances of three noninvasive serological assays for the detection of immunoglobulin G antibodies to leishmania antigen for the diagnosis of imported cases of kala azar (visceral leishmaniasis [VL]) in a country, Kuwait, where the disease is not endemic. A total of 323 individuals including 21 patients with documented cases of VL, 72 individuals with suspected cases of VL, 155 patients with other parasitic infections, and 75 healthy control individuals were tested by indirect hemagglutination assay (IHA; Behring Diagnostics GmbH, Marburg, Germany), indirect fluorescent-antibody assay (IFA; bioMerieux sa, Marcy l'Etoile, France), and a qualitative membrane-based immunoassay with recombinant leishmania antigen K39 (strip-test; Intersep Ltd, Berkshire, United Kingdom). Our data show that IHA is the most sensitive test (100%), followed by IFA (86.6%) and the strip-test (80.0%). The strip-test was the most specific (100%) of the three assays, followed by IFA (93.0%) and IHA (86.0%). However, the strip-test failed to detect at least three confirmed cases of VL. We conclude that IHA is preferred over IFA and the strip-test for the screening of individuals with suspected cases of VL, especially in a country where VL is not endemic and where the number of cases is regular but limited. The details about some of the patients with VL are presented to highlight the diversity of clinical presentations and problems encountered in the diagnosis of VL in a country where VL is not endemic.
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Affiliation(s)
- Jamshaid Iqbal
- Department of Microbiology, Faculty of Medicine, Kuwait University, Safat, Kuwait.
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Amato VS, Padilha AR, Nicodemo AC, Duarte MI, Valentini M, Uip DE, Boulos M, Neto VA. Use of itraconazole in the treatment of mucocutaneous leishmaniasis: a pilot study. Int J Infect Dis 2001; 4:153-7. [PMID: 11179919 DOI: 10.1016/s1201-9712(00)90077-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/1999] [Accepted: 08/25/1999] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE Mucocutaneous leishmaniasis is widely distributed in Brazil, with Leishmania (Viannia) braziliensis being the major etiologic agent. The currently recommended therapy is limited by its parenteral use, high toxicity, and variable efficacy. A clinical pilot study was conducted to analyze itraconazole as an oral alternative for the treatment of mucocutaneous leishmaniasis. METHODS Ten patients were enrolled to receive 4 mg/kg per day (up to 400 mg/d) itraconazole for 6 weeks on an outpatient regimen. Diagnosis was based on clinical otorhinolaryngologic examination, followed by a specific serologic reaction, the Montenegro test and pathologic analysis with immunohistochemical reaction. Healing of the lesions was confirmed by clinical otorhinolaryngologic examination. Side effects were monitored by general clinical assessment, hemoglobin determination, leukocyte counts, and liver function tests, all performed before, during, and 1 month after the end of treatment. RESULTS Six of 10 patients presented healed lesions 3 months after treatment, with a sustained therapeutic response for at least a median period of 14.5 months (range, 12-18 mo). Side effects were not observed. CONCLUSIONS This pilot study demonstrated that itraconazole can be an effective and well-tolerated alternative for the treatment of mucocutaneous leishmaniasis. Further randomized studies and double blind controlled trials are needed to assess the benefits of this drug in the treatment of mucocutaneous leishmaniasis.
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Affiliation(s)
- V S Amato
- Department of Infectious and Parasitic Diseases, Clinics Hospital of University of São Paulo, School of Medicine, São Paulo, Brazil.
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Moskowitz PF, Kurban AK. Treatment of cutaneous leishmaniasis: retrospectives and advances for the 21st century. Clin Dermatol 1999; 17:305-15. [PMID: 10384870 DOI: 10.1016/s0738-081x(99)00049-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- P F Moskowitz
- Department of Dermatology, Boston University School of Medicine, Massachusetts, USA
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Affiliation(s)
- Q A Alsaleh
- Department of Dermatology, Al-Sabah Hospital, Kuwait
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Abstract
Human protozoal infections are ubiquitous and occur worldwide. In many cases, antiprotozoal agents currently in use predate the modern antibiotic era. Despite the relative lag in development of new antiprotozoal agents, the 1990s have witnessed an increasing level of interest in these infections, inspired by international travel and immigration, a growing awareness of antiprotozoal drug resistance, and the significance of acute and recrudescent protozoal infections in immunosuppressed hosts. This review summarizes for nonclinician readers the past, present, and future therapies for common human protozoal infections, as well as pharmacologic mechanisms of action and resistance and common toxicities associated with these agents.
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Affiliation(s)
- M Khaw
- Division of Infectious Diseases, UCLA School of Medicine 90024-1688, USA
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Abstract
The World Health Organization estimates that approximately 400,000 new cases of leishmaniasis occur worldwide each year. Cutaneous leishmaniasis is being encountered more frequently in the United States because of increasing travel and immigration from endemic areas. The indications for treatment and recommended treatment regimens reported in the infectious disease and dermatology literature vary widely. We examine both classic and newly developed therapeutic agents and modalities for cutaneous leishmaniasis. Proper therapy depends on species identification. New World leishmaniasis, in general, requires more aggressive therapy; parenteral antimonials are the drugs of choice. Physical modalities may suffice in most cases of Old World leishmaniasis because of its strong tendency toward spontaneous resolution.
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Affiliation(s)
- A B Koff
- Department of Dermatology, Baylor College of Medicine, Houston, TX 77030-3498
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Zuckerman JM, Tunkel AR. Itraconazole: A New Triazole Antifungal Agent. Infect Control Hosp Epidemiol 1994. [DOI: 10.2307/30145593] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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