Cutaneous Leishmaniasis

Aka: Cutaneous Leishmaniasis, Sporotrichoid Cutaneous Leishmaniasis, Old World Cutaneous Leishmaniasis, New World Cutaneous Leishmaniasis, Mucocutaneous Leishmaniasis, Diffuse Cutaneous Leishmaniasis, Leishmania tropica, Leishmania major, Leishmania leishmania, Leishmania viannia

1. See Also
   1. Visceral Leishmaniasis
2. Epidemiology
   1. See Leishmaniasis
3. Pathophysiology
   1. See Leishmaniasis
   2. Incubation: 2-8 weeks
4. Types
   1. See Visceral Leishmaniasis
   2. Old World Cutaneous Leishmaniasis
      1. Acquired in Africa, Asia and Europe
      2. Causes
         1. Leishmania tropica (urban)
         2. Leishmania major (desert)
         3. Leishmania aethiopica
      3. Description
         1. Incubation 2-24 months
         2. Skin lesion on face or leg
         3. Papule becomes necrotic than hypopigmented scar
   3. New World Cutaneous and Mucocutaneous Leishmaniasis
      1. Acquired in latin america
      2. Causes
         1. Leishmania leishmania (e.g. mexicana, chagasi)
         2. Leishmania viannia (e.g. panamensis, braziliensis)
      3. Description
         1. Nodular or ulcers that heal on hands, ears, face
         2. Metastatic lesions may develop in nose years later
            1. Especially in untreated cases
         3. Mucosal lesion onset at nose and Palate
         4. Lesions are locally destructive of mucosa
   4. Diffuse Cutaneous Leishmaniasis
      1. Description
         1. Massive cutaneous dissemination
         2. No visceral involvement
5. Signs
   1. See Nodular Lymphangitis
   2. Primary Lesion 2 to 8 weeks after sandfly bite
      1. Erythematous Papule forms at sandfly bite site
      2. Papule grows into small Nodule
      3. Forms painless well demarcated ulcer
      4. Ulcer forms overlying crust
   3. Secondary Lesions
      1. Nodular Lymphangitis may occur
      2. Ascending Nodules along lymph chain
   4. Systemic signs (rare in cutaneous disease)
      1. See Visceral Leishmaniasis for systemic disease
      2. Occurs in immunosuppressed patients (e.g. HIV)
      3. Fever
      4. Regional adenopathy
   5. Scarring
      1. Skin lesions spontaneously resolve in months
      2. Healing delayed in some forms (e.g. L. brazilensis)
      3. Round depressed scar forms on healing
6. Differential Diagnosis
   1. Skin lesions: Nodular Lymphangitis
   2. Mucosal lesions
      1. See Oral Ulcer
7. Diagnosis
   1. Skin scraping (5 slides)
      1. Remove crust before scraping
      2. Scrape lesion margin and central ulcer
   2. Punch Biopsy ulcer edge
   3. Needle aspirate
      1. Inject saline into border via skin
      2. Aspirate while inserting and withdrawing needle
      3. Culture aspirate on Nicolle-Novy-MacNeal media
8. Management
   1. See Visceral Leishmaniasis for systemic Leishmaniasis
   2. Cutaneous Leishmaniasis
      1. Treatment duration: 20 days
      2. Apply Local Heat to area for 2-3 hours per day
      3. Preferred agents: Pentavalent antimony
         1. Stibogluconate sodium (Pentostam)
            1. Dose: 20 mg/kg/day for 20 days
         2. Meglumine antimonate (Glucantime)
            1. Dose: 20 mg/kg/day for 20 days
      4. Other antimicrobial options (unproven or toxic)
         1. Amphotericin B
            1. Dose: 0.5-1.0 mg/kg PO every other day x8 weeks
            2. Indicated for cases refractory to antimony
         2. Pentamidine isoethionate (Pentam 300)
            1. Significant toxicity
         3. Topical paromomycin
            1. Effective for L. major and L. mexicana
         4. Allopurinol
            1. Not currently recommended due to unclear data
            2. Synergistic effect with antimonial agents
         5. Azole Antifungals
         6. Consider intralesional injection
   3. Diffuse or Mucocutaneous Leishmaniasis
      1. Treatment duration: 30 days
      2. Sodium Antimony Gluconate 20 mg/kg IV/IM qd
9. Prevention
   1. See Prevention of Vector-borne Infection
   2. Insect Repellant
10. References
    1. Herwaldt (1999) Lancet 354:1191-9
    2. Pearson (1996) Clin Infect Dis 22:1-13
    3. Tobin (2001) Am Fam Physician 63(2):326-32
    4. Markle (2004) Am Fam Physician 69(6):455-60