What is the treatment for cutaneous leishmaniasis?

Treatment of Cutaneous Leishmaniasis

For simple, localized cutaneous leishmaniasis lesions (small, recent-onset, uncomplicated), local therapy with intralesional pentavalent antimonials, heat therapy, or cryotherapy should be the preferred first-line approach, while complex cases (multiple lesions, lesions >4cm, facial/joint involvement, or species with mucosal risk) require systemic therapy with liposomal amphotericin B, pentavalent antimonials, or miltefosine. 1

Treatment Selection Algorithm

Step 1: Classify the Lesion as Simple vs. Complex

Simple CL (suitable for local therapy): 1

• Small lesions (<30mm width)
• Single or few lesions
• Recent onset (<3 months)
• Non-ulcerative or small ulcerative forms
• NOT on eyelids, lips, nose, ears, or fingers
• No evidence of dissemination (no subcutaneous nodules or regional adenopathy)
• NOT caused by New World species with mucosal risk (L. braziliensis, L. panamensis, L. guyanensis)

Complex CL (requires systemic therapy): 1

• Multiple lesions or large lesions (>4cm)
• Lesions on face, joints, or near mucosal areas
• Evidence of lymphatic spread
• Caused by species with mucosal leishmaniasis risk
• Immunocompromised patients
• Lesions present >6 months

Step 2: Local Therapy Options for Simple CL

Intralesional Pentavalent Antimonials (First Choice for Simple OWCL): 1

• Use undiluted sodium stibogluconate or meglumine antimoniate
• Dose: 0.1 mL/cm² injected intradermally with 25-27G needle
• Volume: 0.2-5 mL per session at up to 4-5 injection sites
• Frequency: Every 3-7 days for 5-8 sessions until healing
• Pre-medicate with EMLA cream (lidocaine/prilocaine) for pain control
• Avoid on fingers, nose, ears, eyelids, near lips, or areas of vascular concern
• Success rates: 89-91% when combined with cryotherapy 1

Cryotherapy (Especially Effective When Combined with IL Antimonials): 1

• Apply liquid nitrogen for 15-20 seconds until 1-2mm of surrounding skin frozen
• Thaw 20-60 seconds, then repeat freeze
• Repeat entire process every 3 weeks for up to 3 applications
• When combined with intralesional antimonials: use shorter application (no second freeze), allow skin to normalize, then inject antimonials
• Best for lesions <30mm, on face/neck, dry, present <3 months
• Avoid eyelids, lips, nose, ears
• Safe in pregnancy and breastfeeding 1

Heat Therapy (ThermoMed Device): 1

• Apply at 50°C for 30-second doses in grid pattern
• Extend 1-2mm into normal-appearing skin
• Usually one session (sometimes up to 3)
• Use topical antibiotics for several days post-treatment
• Avoid same anatomical sites as cryotherapy
• FDA-cleared for CL indication 1

Topical Paromomycin: 1

• 15% paromomycin + 12% MBCL ointment: apply BID for 10 days, rest 10 days, reapply BID for 10 days
• OR 15% paromomycin + 0.5% gentamicin cream: apply once daily for 20 days
• Higher response rates for L. major than L. tropica 1

Step 3: Systemic Therapy Options for Complex CL

Liposomal Amphotericin B (Preferred for Species with Mucosal Risk): 2

• Dose varies by species and geography; typically 3 mg/kg/day
• Less toxic than conventional amphotericin B deoxycholate
• Particularly important for L. braziliensis, L. panamensis, L. guyanensis 2

Pentavalent Antimonials (Sodium Stibogluconate or Meglumine Antimoniate): 1, 2, 3

• Dose: 20 mg SbV/kg/day IV or IM for 20 days (cutaneous) or 28 days (mucosal)
• No upper limit on daily dose (remove the 850mg cap) 3
• Efficacy: 62-95% for cutaneous leishmaniasis 4, 5
• Alternative regimen: 5 mg SbV/kg/day IM for 30 days (less toxic, 84% efficacy) 4
• Requires laboratory monitoring (hepatic, renal, cardiac function)
• Both sodium stibogluconate and meglumine antimoniate show similar efficacy 5

Miltefosine (Only Oral Option): 1, 6

• FDA-approved for CL due to L. braziliensis, L. guyanensis, L. panamensis
• Dose: If 30-44 kg: 50mg BID for 28 days; if ≥45 kg: 50mg TID for 28 days
• Target dose: ~2.5 mg/kg/day
• Efficacy: 66% overall (82% for L. braziliensis in Colombia, 48% in Guatemala, 67.5-85% in Brazil) 6
• Good evidence for Old World CL; variable results for New World CL depending on species and geography 1
• Contraindicated in pregnancy (teratogenic); requires effective contraception during and 2 months post-therapy 6

Critical Pitfalls to Avoid

Do NOT use local therapy alone for: 1

• New World CL species that can cause mucosal leishmaniasis (L. braziliensis, L. panamensis, L. guyanensis)
• Patients with evidence of dissemination (subcutaneous nodules, regional adenopathy)
• Lesions on high-risk anatomical sites (eyelids, lips, nose, ears, fingers)

Do NOT switch to amphotericin B deoxycholate if patient has toxicity with liposomal amphotericin B, as conventional formulation is almost always more toxic 2

Debride eschar overlying ulcers before local therapy and manage secondary infection to maximize treatment effect 1

Monitoring Treatment Response

Clinical criteria (not parasitologic testing): 1, 2

• Lesion flattening and >50% size decrease by 4-6 weeks
• Re-epithelialization of ulcerative lesions by approximately 3 months
• Healing may continue after treatment completion, especially for large ulcers
• Monitor for 6-12 months post-treatment for relapse

Mucosal surveillance: 1

• Perform careful nasal and oropharyngeal examination periodically up to 1-2 years
• Educate patients about signs of mucosal involvement (nasal stuffiness, epistaxis, hoarseness)
• Any suspicious symptoms warrant fiber-optic examination

Special Populations

Pregnancy/Breastfeeding: 1

• Cryotherapy is safe
• Avoid miltefosine (teratogenic)
• Pentavalent antimonials have limited safety data

Immunocompromised: 1

• Always use systemic therapy
• Higher risk of dissemination
• May require combination therapy or higher doses