Treatment of Cutaneous Leishmaniasis Caused by Leishmania aethiopica: A Systematic Review.

Johan Van Griensven,Abraham Aseffa,Ermias Diro,Abate Mulugeta Beshah,Asrat Hailu,Endalamaw Gadisa,Hechmi Louzir

doi:10.1371/journal.pntd.0004495

Abstract

Leishmania aethiopica is the etiological agent of cutaneous leishmaniasis (CL) in Ethiopia and can cause severe and complicated cases such as diffuse CL (DCL), mucocutaneous leishmaniasis or extensive CL, requiring systemic treatment. Despite the substantial burden, evidence-based treatment guidelines are lacking. We conducted a systematic review of clinical studies reporting on treatment outcomes of CL due to L aethiopica in order to help identify potentially efficacious medications on CL that can be taken forward for clinical trials. We identified a total of 24 records reporting on 506 treatment episodes of CL presumably due to L aethiopica. The most commonly used drugs were antimonials (n = 201), pentamidine (n = 150) and cryotherapy (n = 103). There were 20 case reports/series, with an overall poor study quality. We only identified two small and/or poor quality randomized controlled trials conducted a long time ago. There were two prospective non-randomized studies reporting on cryotherapy, antimonials and pentamidine. With cryotherapy, cure rates were 60–80%, and 69–85% with antimonials. Pentamidine appeared effective against complicated CL, also in cases non-responsive to antimonials. However, all studies suffered from methodological limitations. Data on miltefosine, paromomycin and liposomal amphotericin B are extremely scarce. Only a few studies are available on DCL. The only potentially effective treatment options for DCL seem to be antimonials with paromomycin in combination or pentamidine, but none have been properly evaluated. In conclusion, the evidence-base for treatment of complicated CL due to L aethiopica is extremely limited. While antimonials remain the most available CL treatment in Ethiopia, their efficacy and safety in CL should be better defined. Most importantly, alternative first line treatments (such as miltefosine or paromomycin) should be explored. High quality trials on CL due to L aethiopica are urgently needed, exploring group sequential methods to evaluate several options in parallel.

Highlights

Cutaneous leishmaniasis (CL) is a chronic infectious skin disease caused by a group of protozoan parasites of the Leishmania genus
Cutaneous leishmaniasis (CL) refers to skin ulcers caused by the Leishmania parasite, which is transmitted by the bite of sandflies
CL in Ethiopia can be associated with severe and complicated disease such as diffuse CL (DCL), which presents with multiple skin lesions spread over the body

Summary

Introduction

Cutaneous leishmaniasis (CL) is a chronic infectious skin disease caused by a group of protozoan parasites of the Leishmania genus. Ulcerative skin lesions occurring at the site of the bite of the sandfly is the most common cutaneous manifestation (localized CL—LCL). Mucosal leishmaniasis (ML) or mucocutaneous CL (MCL) refers to an often destructive form with mucosal inflammation, which has been mainly reported in the New World—in association with L braziliensis [1,2]—and in the Old World [3]. In the New World, L braziliensis causes the largest CL burden, with Brazil most severely affected. In the Old World, most cases are found in the Middle East, North Africa, the Indian subcontinent and Central Asia [4]

Objectives

Methods

Results

Discussion

Conclusion