Overview systemic treatment of cutaneous leishmaniasis

• Pentavalent antimonials (meglumine antimonate [85 mg Sb/ml, IM] or sodium stibogluconate [100 mg/ml, IV]. Duration of treatment is not standarised (e.g. 14 to 28 days).

• Pentamidine. First line against L. guyanensis (French Guyana). Check glycaemia. Several treatment schemes exist and the cure rate is dose-dependent. Some short-courses use 1200 mg as a total dose. In Guyana 3 mg/kg/day every other day is often used (4 injections).

• Imidazoles, triazoles. Fluconazole promising against L. major. Ketoconazole 600 mg per day x 28 days is moderately effective for L. mexicana, but much lower against L. braziliensis.

• Miltefosine. Still experimental.

• Amphotericine B and its liposomal formulation

• Allopurinol. Not as monotherapy, but associated with e.g. pentavalent antimony for L. panamensis.

Glucantime® (meglumine antimonate) or Pentostam® (stibogluconate) can be injected intralesionally (that is, into the edge of the lesion itself) as a treatment for cutaneous leishmaniasis. These can be given parenterally for extensive lesions. Varying results have also been reported with allopurinol (Zyloric®), which can be given orally. Topical treatments with heating (40C to 42C for 12 hours), freezing with liquid nitrogen and paromomycin ointment (15% aminosidine in methylbenzethonium BD x 15-30 days) have been used with varying success. Itraconazole (Sporanox®) gave good results in initial studies, but is still controversial. Ketoconazole is sometimes used, but is use is often complicated by hepatotoxicity, abdominal pain and nausea. Imiquimod 5% cream (Aldara®) is an immunomodulating substance, initially used for warts caused by papilloma virus. Its use in cutaneous leishmaniasis is still experimental.

Infections caused by Leishmania major can be successfully treated with oral fluconazole 200 mg/day for 6 weeks (cure rate of 80%).

The treatment of diffuse cutaneous leishmaniasis caused by L. aethiopica is problematical, as this parasite is less sensitive to Glucantime®. Pentamidine can be used against L. aethiopica. A dose of 4 mg/kg/week which has to be continued for at least 4 months after disappearance of the parasites from the skin is an acceptable guideline here. Parenteral aminosidine sulphate is another therapeutic possibility. This is an antibiotic that is obtained from Streptomyces chrestomyceticus. It is an aminoglycoside and is thus potentially nephro- and ototoxic. It is chemically identical to paromomycin, which is obtained from a related Streptomyces strain. The compound is not resorbed from the intestine. Recurrences are frequently seen with aminosidine given as monotherapy. Aminosidine is, however, synergistic with stibogluconate and a permanent remission can be obtained with the combination of aminosidine with Glucantime® or Pentostam®. The dose is 14 mg/kg/day IM to be continued for up to 60 days after all parasites have been eliminated. The total treatment period takes 6 months or more. Good results were obtained with amphotericin B.

Category: Medicine Notes