Tropical medicine rounds:   Treatment of Old World cutaneous leishmaniasis with dapsone, itraconazole, cryotherapy, and imiquimod, alone and in combination.
BACKGROUND
Cutaneous leishmaniasis (CL) is a major public health problem. The currently available therapies are expensive, not freely available, toxic, and not always curative. A simple, effective, noninvasive therapeutic approach is required for the treatment of CL.


OBJECTIVE
To determine the clinical patterns of CL and to report our experience in the management of CL.


METHODS
One hundred and ten patients with CL seen between January 2005 and December 2007 were included in this study. The diagnosis was based on clinical features, parasitologic diagnosis, histopathology, and culture. Each patient was treated according to disease severity with either topical (cryotherapy or imiquimod) or systemic (itraconazole or dapsone) monotherapy, or a combination of these modalities.


RESULTS
CL was more common in adult expatriate men, with the upper limbs as the most commonly affected site. Noduloulcerative CL was the most common presentation (84.6%). Atypical CL was found in 18 patients. Skin biopsy was the most common diagnostic technique (66.6%). Monotherapy showed an overall success rate of 56.41%, whereas combination therapy was successful in 69.56% of cases. Cryotherapy alone was successful in 68.18% of cases. Imiquimod alone was ineffective.


CONCLUSIONS
A stepwise approach represents a rational and practical way of confirming CL. A combination of itraconazole/dapsone and topically applied imiquimod is safe, simple, and effective for the treatment of CL. More studies are needed to establish the role of such an approach. Cryotherapy is also safe, simple and effective for the treatment of CL.
Al-Mutairi
Nawaf
N
Department of Dermatology, Institutional Affiliation, Farwaniya Hospital, Kuwait. nalmut@usa.net
Alshiltawy
Mazen
M
El Khalawany
Mohamed
M
Joshi
Arun
A
Eassa
Bayoumy Ibrahim
BI
Manchanda
Yashpal
Y
Gomaa
Samir
S
Darwish
Ibrahim
I
Rijhwani
Manish
M
D000276:Adjuvants, Immunologic / Q000008:administration & dosage; D000293:Adolescent; D000328:Adult; D000554:Ambulatory Care Facilities; D000634:Aminoquinolines / Q000008:administration & dosage*; D000890:Anti-Infective Agents / Q000008:administration & dosage; D000981:Antiprotozoal Agents / Q000008:administration & dosage; D003131:Combined Modality Therapy; D017679:Cryotherapy; D003622:Dapsone / Q000008:administration & dosage*; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D000077271:Imiquimod; D017964:Itraconazole / Q000008:administration & dosage*; D007730:Kuwait; D016773:Leishmaniasis, Cutaneous / Q000188:drug therapy* / Q000473:pathology; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D055815:Young Adult
D000276:Adjuvants, Immunologic; D000634:Aminoquinolines; D000890:Anti-Infective Agents; D000981:Antiprotozoal Agents; D017964:Itraconazole; D003622:Dapsone; D000077271:Imiquimod