Local or systemic treatment for New World cutaneous leishmaniasis? Re-evaluating the evidence for the risk of mucosal leishmaniasis

Abstract

This review addresses the question of whether the risk of developing mucosal leishmaniasis (ML) warrants systemic treatment in all patients with New World cutaneous leishmaniasis (CL) or whether local treatment might be an acceptable alternative. The risk of patients with New World CL developing ML after the initial infection has been the main argument for systemic treatment. However, this statement needs re-evaluation and consideration of all the available data. The putative benefit of preventing ML should outweigh the toxicity of systemic antileishmanial therapy. To assess the need for and risk of systemic treatment the following factors were reviewed: the incidence and prevalence of ML in endemic populations and in travellers; the severity of mucosal lesions; the efficacy of current options to treat ML; the toxicity and, to a lesser extent, the costs of systemic treatment; the risk of developing ML after local treatment; and the strengths and limitations of current estimates of the risk of developing ML in different situations. Local treatment might be considered as a valuable treatment option for travellers suffering from New World CL, provided that there are no risk factors for developing ML such as multiple lesions, big lesions (>4 cm(2)), localisation of the lesion on the head or neck, immunosuppression or acquisition of infection in the high Andean countries, notably Bolivia.

Quantitative Kinetoplast DNA Assessment During Treatment of Mucosal Leishmaniasis as a Potential Biomarker of Outcome: A Pilot Study

“…Our findings reiterate that good evidence to support a protective role of initial parenteral, oral, or local treatment of CL in the pathogenesis of ML is lacking. 33,34 Species identification is important in countries such as Peru where several members of the L. (Viannia) subgenus are co-endemic and portend different clinical prognoses and response to therapy. 35 Leishmania (Viannia) braziliensis is the most well-represented causative species in ML.…”

Species Typing in Dermal Leishmaniasis

“…Also, vaccines targeting one particular group of parasites may be deployed. Second, clinical presentations may differ according to the geographical region or human population, for instance, in travelers versus individuals with endemic cases (18). Third, for prevention and control, different species can have different transmission cycles, requiring other control measures.…”

Local Delivery of the Toll-Like Receptor 9 Ligand CpG Downregulates Host Immune and Inflammatory Responses, Ameliorating Established Leishmania (Viannia) panamensis Chronic Infection

“…Additionally, mice were treated perilesionally, as local rather than systemic treatment would be a less toxic approach and reduce side effects. Local treatment is considered preferable and acceptable for single, small, localized uncomplicated lesions in the absence of risk factors for mucocutaneous disease (45,46). The relatively high dose of 50 g of CpG was used, as it had been previously demonstrated to elicit the induction of Tregs after either systemic (28,34,47) or dermal (48,49) delivery of CpG.…”