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).
