This protocol addresses immunocompetent patients with clinically simple cutaneous leishmaniasis — a single or a few small skin lesions (under 1 cm in diameter) confined to nonexposed skin, caused by a Leishmania species not associated with mucosal disease and with no mucosal involvement — in whom an initial course of local therapy has not met the expected response milestones.
Clinically simple cutaneous leishmaniasis as defined by Table 1 criteria: lesions are small, located on nonexposed skin, there is no mucosal involvement, and the host is immunocompetent. The causative species is one not typically linked to mucosal leishmaniasis.
An initial course of local therapy — which may include heat therapy, cryotherapy, intralesional pentavalent antimonial, or topical paromomycin — has not achieved the expected response. At 4–6 weeks, the lesion has not decreased in size by more than 50%, ulcerative lesions are not reepithelializing, or new lesions are appearing. Failure to reach these local-therapy targets indicates a need for systemic treatment.
By 4–6 weeks after treatment, lesion size should have decreased by more than 50%, ulcerative lesions should be reepithelializing, and no new lesions should be appearing. Ulcerative lesions are generally fully healed by approximately 3 months after treatment.
DOI: 10.1093/cid/ciw670
We recommend that immunocompetent persons with skin lesions that are caused by infection with Leishmania species that are not associated with increased risk for ML, that are defined as clinically simple lesions (Table 1), and that are healing spontaneously may be observed without treatment if the patient concurs with this management.
Local therapy is preferred for treatment of Old World cutaneous leishmaniasis (OWCL) lesions defined as clinically simple (Table 1) and may be useful for localized NWCL caused by Leishmania species not associated with increased risk for ML.
The parenteral options for systemic therapy currently available in North America include conventional amphotericin B deoxycholate, lipid formulations of amphotericin B, pentavalent antimonial (SbV) compounds, and pentamidine (listed in alphabetical order).
Oral options include miltefosine and the "azole" antifungal compounds, including ketoconazole (if potential benefits outweigh risks for hepatotoxicity and QT prolongation) and fluconazole.
By 4–6 weeks after treatment, the lesion size should have decreased by >50%, ulcerative lesions should be reepithelializing, and no new lesions should be appearing.
Ulcerative lesions are generally fully reepithelialized and clinically healed by approximately 3 months after treatment.
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