12
35. The parenteral options for systemic therapy currently available in
North America include conventional amphotericin B deoxycholate,
lipid formulations of amphotericin B, pentavalent antimonial (SbV)
compounds, and pentamidine (listed in alphabetical order). Oral
options include miltefosine and the "azole" antifungal compounds,
including ketoconazole (if potential benefits outweigh risks for
hepatotoxicity and QT prolongation) and fluconazole [FACT, no grade].
36. To maximize effectiveness and to minimize toxicity, the choice of
agent, dose, and duration of therapy should be individualized (S-M).
Remarks: No ideal or universally applicable therapy for CL has been identified. Some
therapies/regimens appear highly effective only against certain Leishmania species/
strains in certain areas of the world. Both the parasite species and host factors (eg,
comorbid conditions and immunologic status) should be considered.
37. Factors that should be considered when selecting CL treatment for
an individual patient include: (S-L)
• the risk for ML
• the Leishmania strain/species and published response rates for antileishmanial
agents in the pertinent geographic region
• the potential for adverse events
• age extremes
• childbearing competence and pregnancy
• obesity
• hepatic, pancreatic, renal, and cardiac comorbid conditions
• preference for and convenience of various routes of administration
• the rapidity with which one wishes to control the infection
• the impact of lesions on daily activities and patient self-confidence
• the patient/provider comfort level with logistics (eg, Investigational New Drug
protocols)
• other practical issues (eg, drug availability, various types of cost, insurance
reimbursement)
Note: See Recs. 32–34 and 78–79; Tables 3 and 4 and http://cid.oxfordjournals.org/
content/suppl/2016/11/03/ciw670.DC1/ciw670supp.xls
Clinical Settings
38. Local therapy is preferred for treatment of OWCL lesions defined as
clinically simple (Table 1) and may be useful for localized NWCL caused
by Leishmania species not associated with increased risk for ML (S-M).
Remark: Local therapy includes heat and cryotherapy, topical ointments/creams
with paromomycin and other ingredients, intralesional injections of pentavalent
antimonial drugs (± cryotherapy), and photodynamic or laser treatment.
39. Eschar(s) overlying ulcers should be debrided before administration
of local therapy and any secondary infection managed to maximize
treatment effect (S-VL).
Treatment
