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Leishmaniasis

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11 27. The Panel recommends that any decision to observe a patient with CL without treatment should be reevaluated periodically, and the decision not to treat should be reconsidered if healing does not progress as anticipated (S-VL). 28. In all cases of CL, wound care, individualized documentation of lesion evolution, and patient education regarding the manifestations and detection of local therapeutic failure/relapse and ML should be routine components of management (S-L). Inadequate Treatment 29. Potential consequences of inadequate treatment include poor cosmetic outcome due to scarring or superinfection, the persistence of a chronic wound(s), and, with some Leishmania species, destructive and disfiguring ML. In immunocompromised persons, cutaneous, mucosal, and visceral dissemination may occur (FACT, no grade). 30. Persons with CL should be actively monitored by clinical appearance, including by performing a careful nasal and oropharyngeal examination periodically up to 1 year, or at least 2 years if at increased risk for ML. They should be educated about the signs and symptoms of relapse and ML and instructed to seek medical attention anytime these appear (S-L). 31. Symptoms such as chronic nasal stuffiness, epistaxis, or hoarseness or findings such as septal perforation that occur anytime in a person with a prior or current diagnosis of CL or a scar consistent with prior CL should prompt evaluation for ML, including fiberoptic examination of the affected area if relevant (see Recs. 10–16) (S-M). Systemic Treatment 32. Systemic treatment is recommended for persons with complex CL as defined in Table 1 (S-M). 33. Initial systemic therapy (see Recs. 35–37) may be used in persons with CL in whom it is not practical to use local therapy or (possibly) if more rapid healing of large, cosmetically or functionally concerning lesions is preferred (W-VL). 34. Less common cutaneous syndromes, such as leishmaniasis recidivans (caused by L. tropica and occasionally other species), diffuse cutaneous leishmaniasis (caused by L. mexicana, L. amazonensis, and L. aethiopica), and disseminated cutaneous leishmaniasis (caused by L. [V.] braziliensis), usually require systemic therapy (S-L).

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