Topical Treatment of Cutaneous Leishmaniasis in Israel, Part 1.

Cutaneous leishmaniasis is the most common form of leishmaniasis with global incidence of about 1.5 million cases annually. The disease is endemic in Israel and caused by two types, Leishmania major and Leishmania tropica. The two types of cutaneous leishmaniasis in Israel are not life threatening, but the multiple skin lesions developed from the contaminated sandfly bites cause significant damage to the quality of life for a few months in patients with Leishmania major and sometimes for more than a year in patients with Leishmania tropica. The disease ends spontaneously, often with disfiguring scars. The aim of the treatment is to significantly shorten the wound-healing process, hopefully with minimal scars and with parasite eradication. Topical treatment for this localized skin disease is very attractive, although only one medication is registered in Israel (15% paromomycin +12% methylbenzethonium chloride ointment), which is for the topical treatment of "Leishmania major." Relatively low efficacy and significant irritation and pain are two significant disadvantages that characterize this topical medication and could result in failure of the registered treatment. This article, which is presented in 3 parts, discusses three options in the treatment of cutaneous leishmaniasis, 1) amphotericin B liposomal gel and 2) paromomycin sulfate liposomal gel (free of the sensitizing methylbenzethonium chloride), both of which the author considers as efficacious in the treatment of cutaneous leishmaniasis, although to confirm these claims, randomized controlled trials must be conducted, and 3) photodynamic therapy. Most of the reports claim that the photodynamic therapy can achieve results above 90% healing of wounds in a relatively short period of time and with relatively minimal scars. However, a caveat must be held since some of these studies indicate that not all healed wounds become free of the parasite. The daylight option of photodynamic therapy is an interesting modality which abolishes the need for an expensive artificial light source and expensive hospitalization time and enables ambulatory treatment to be efficacious against both types of Leishmania in Israel. Formulations are provided for the three modalities, with the third option being based on 5-aminolevulinic acid hydrochloride as the photosensitizer for this therapy.
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