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

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II. Epidemiology

  1. See Leishmaniasis

III. Pathophysiology

  1. See Leishmaniasis
  2. Incubation: 2-8 weeks

IV. Types

  1. See Visceral Leishmaniasis
  2. Simple Cutaneous Leishmaniasis (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. Single Papule forms at sandfly bite site on face or leg
      3. Papule necroses and forms a single ulcer ("oriental sore")
        1. Leishmania can be seen in ulcer bed scrapings under microscopy
      4. Ulcer heals over the course of the year
        1. Hypopigmented scar remains at bite site
    4. Cell mediated Immunity limits infection to localized skin lesion
      1. Future delayed Hypersensitivity to Leishmania
      2. Leishmanin Skin Test
        1. Intradermal injection of LeishmaniaAntigen results in PPD-like reaction at 48-72 hours
  3. Mucocutaneous Leishmaniasis (New World Leishmaniasis)
    1. Acquired in latin america
    2. Causes
      1. Leishmania leishmania (e.g. mexicana, chagasi)
      2. Leishmania viannia (e.g. panamensis, braziliensis)
    3. Begins with Nodules or Skin Ulcers at sandfly bite (as with simple Cutaneous Leishmaniasis)
      1. Lesions are typically on the hands, ear or face
    4. Mucous membrane ulcers form on mouth and nose, months to years after Skin Ulcer heals
      1. Mucosal lesions are destructive (esp. nose, Palate)
      2. Lesion scrapings demonstrate Leishmania under microscopy
    5. Chronic infections in untreated patients leads to erosions of the nasal septum, Palate and lips
      1. Lesions develop over decades in untreated patients
      2. Complications (esp. secondary Bacterial Infections) may be lethal
  4. Diffuse Cutaneous Leishmaniasis
    1. Less common than other forms of Leishmaniasis
      1. Associated with specific Leishmania species (e.g. L. amazonensis, L. mexicana, L. aethiopica)
      2. Most severe cases reported in Brazil, Ethiopia, Sudan, South Sudan, India, and Bangladesh
    2. Chronic form of Cutaneous Leishmaniasis in Immunocompromised patients
      1. Cell mediated Immunity deficiency allows for chronic smoldering infection
      2. Promastigotes persist in the skin and spread systemically (but no visceral involvement)
      3. Leishmanin Skin Test is negative due to deficient cell mediated Immunity
    3. Nodular skin lesion forms at sandfly bite but does not ulcerate
    4. Diffuse skin Nodules develop over time, distant from the initial bite site
      1. Predisposition for perinasal lesions
    5. Infection persists for decades in untreated patients

V. 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

VI. Differential Diagnosis

  1. Skin lesions: Nodular Lymphangitis
  2. Mucosal lesions
    1. See Oral Ulcer

VII. 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

VIII. Management

  1. See Visceral Leishmaniasis for systemic Leishmaniasis
  2. Mild Cutaneous Leishmaniasis
    1. Treatment duration: 20 days
    2. Apply Local Heat to area for 2-3 hours per day
    3. Many lesions heal with observation alone
    4. Paromomycin ointment twice daily on days 1-10 and 20-30
      1. Apply in two cycles of 10 days each with 10 intervening days between
    5. Intralesional Meglumine antimonate (Glucantime)
      1. Inject undiluted solution intralesionally
      2. Inject up to 20 mg/kg total or 850 mg of antimony component weekly for 5-10 weeks
      3. May be combined with Cryotherapy
    6. Other local therapy
      1. Cryotherapy (up to 3 times)
      2. Laser Therapy
  3. Complex or Diffuse Cutaneous Leishmaniasis (including all cases of Leishmania braziliensis)
    1. Meglumine Antimoniate (Glucantime)
      1. Dilute intravenous doses in 50 ml D5W or NS prior to administration and deliver over >=20 minutes
      2. Inject 20 mg/kg/day up to 850 mg (of antimony component) IV or IM daily for 20 days (28 days for mucosal)
    2. Liposomal Amphotericin B
      1. Dose 3 mg/kg IV daily for 7 days
      2. Dosing regimen is modified for L. braziliensis (see other references)
    3. Alternative agents (see other references for dosing)
      1. Miltefosine
      2. Azole Antifungals (Fluconazole, Ketoconazole)
  4. Mucosal Leishmaniasis
    1. Liposomal Amphotericin B
      1. See other resources for dosing regiments
    2. Meglumine Antimoniate (Glucantime)
      1. See above for dosing regimen
      2. Mucosal Leishmaniasis treatment duration for 28 days
    3. Alternative agents
      1. Miltefosine may be effective in some cases

IX. Prevention

  1. See Prevention of Vector-borne Infection
  2. Insect Repellent

X. References

  1. Freedman (2025) Sanford Guide, accessed 7/13/2025 on IOS
  2. Gladwin, Trattler and Mahan (2014) Clinical Microbiology, Medmaster, Fl, p. 348-9
  3. de Vries (2022) Am J Clin Dermatol 23(6):823-40 +PMID: 36103050 [PubMed]
  4. Herwaldt (1999) Lancet 354:1191-9 [PubMed]
  5. Pearson (1996) Clin Infect Dis 22:1-13 [PubMed]
  6. Tobin (2001) Am Fam Physician 63(2):326-32 [PubMed]
  7. Markle (2004) Am Fam Physician 69(6):455-60 [PubMed]

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