Cutaneous leishmaniasis (CL) is not always amenable to local treatment. When the presentation meets criteria for complex CL, systemic antileishmanial therapy is the recommended approach regardless of geographic setting.
Any of the following defines complex CL and warrants systemic management:
By 4–6 weeks after treatment, lesion size should have decreased by more than 50%, ulcerative lesions should be re-epithelializing, and no new lesions should be appearing. Full clinical healing is generally expected by approximately 3 months after treatment.
Systemic treatment is recommended for persons with complex CL as defined in Table 1.
Less common cutaneous syndromes, such as leishmaniasis recidivans (caused by L. tropica and occasionally other species), diffuse cutaneous leishmaniasis (caused by L. mexicana, L. amazonensis, and L. aethiopica), and disseminated cutaneous leishmaniasis (caused by L. [V.] braziliensis), usually require systemic therapy.
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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