Non-Ablative Fractional 1,540-nm Er:Glass Laser in the Treatment of Atrophic Cutaneous Leishmaniasis Scars.

OBJECTIVES: To evaluate the efficacy of nonablative fractional 1,540 nm laser to treat the atrophic scars caused by the cutaneous leishmaniasis (CL). METHODS: This clinical trial with a pre- and a posttreatment measurement was conducted on patients with atrophic CL scars. The lesions were treated with nonablative fractional 1,540 nm laser. We evaluated the patients initially and then monthly, before each treatment session. The final follow-up was done 6 months after the end of study for all patients. Patient assessment was performed by two physicians using the modified Manchester Scar Scale (MSS) as well as the interpretation of captured digital photographs. Moreover, the patients performed a self-assessment by filling in a researcher-made questionnaire. The data were statistically analyzed by SPSS software. P < 0.05 was considered statistically significant. RESULTS: Thirty patients with 37 skin lesions participated in the study. The pairwise comparison demonstrated a statistically significant difference between the modified MSS parameters (P < 0.05); however, no significant difference was observed between the modified MSS of the third and fourth (P = 0.82) as well as fourth and fifth (P = 0.636) sessions. The lesions improvement was significant based on the physician's evaluation (P < 0.001). Furthermore, patients' level of satisfaction was significantly increased in all six follow-ups (P < 0.001). No persistent complication was found. CONCLUSIONS: Nonablative fractional 1,540 nm laser is an effective and safe therapeutic choice for atrophic CL, even in darker skins. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Curcumin-loaded self-emulsifying drug delivery system (cu-SEDDS): a promising approach for the control of primary pathogen and secondary bacterial infections in cutaneous leishmaniasis.

Cutaneous leishmaniasis being a neglected tropical disease (NTD) faces several challenges in chemotherapy. If infected with secondary bacterial infections, the treatment regime of cutaneous ulcers in cutaneous leishmaniasis is further complicated which usually require two or more than two chemotherapeutic agents for healing. In the current study, seven curcumin-loaded self-emulsifying drug delivery system (cu-SEDDS) formulations (namely F1-F7) were prepared by mixing different excipients (oils, surfactants, and co-solvents) through stirring (vortex) and sonication. The formulations were characterized regarding their droplet size, polydispersity index (PDI), and zeta potential by zeta sizer. The cu-SEDDS formulations displayed different sizes ranging from 32.4 up to 80.0 nm. The zeta potential of the formulations ranged from - 1.56 up to - 4.8. The antileishmanial activities of the cu-SEDDS formulations in terms of IC50 against Leishmania tropica ranged from 0.19 up to 0.37 µg/ml. The minimum inhibitory concentrations (MICs) of these formulations against Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiella pneumoniae were in the range of 48-62 µg/ml. The hemolysis caused by formulations was 1-2%. The spreading potential of the formulations (F1 and F5) over damaged skin model was remarkable. These results suggest that cu-SEDDS further enhanced the broad spectrum antileishmanial and antibacterial profile of curcumin and could be used for the treatment of cutaneous leishmaniasis and its associated secondary infections.

In Vitro and In Vivo Control of Secondary Bacterial Infection Caused by Leishmania major.

Bacterial infections of cutaneous leishmaniasis cause skin ulcers on mice, resulting in increased tissue deterioration, and these infections can be controlled with liquid allicin. To isolate and identify the incidences of real secondary bacterial infections in mice, we performed the current study by injecting mice (n = 50) with Leishmania major. L. major infections were initiated by an intramuscular injection of 0.1 mL Roswell Park Memorial Institute (RPMI 1640 media/mouse (107 promastigote/mL)). Scarring appeared 2-6 weeks after injection, and the bacteria were isolated from the skin ulcer tissues. Allicin (50 µL/mL) and ciprofloxacin (5 µg; Cip 5) were used for controlling L. major and bacteria. One hundred samples from skin ulcers of mice were examined, and 200 bacterial colonies were isolated. Forty-eight different genera and species were obtained and identified by Gram staining and physiological and biochemical characterization using identification kits. All samples were positive for secondary bacterial infections. Of the isolates, 79.16% were identified as Gram-negative bacteria, and 28.84% were identified as Gram-positive bacteria; only one yeast species was found. Interestingly, pure allicin liquid at a concentration 50 µL/mL exhibited antibacterial activity against a wide range of Gram-negative and some Gram-positive bacteria, in addition to yeast, and was 71.43% effective. Antimicrobial resistance patterns of all genera and species were determined using 15 different antibiotics. Allicin (50 µL/mL) and Cip 5 were the most effective against L. major and 92.30% of isolated bacteria. Stenotrophomonas maltophilia was the most resistant bacterium to the tested antibiotics with a survival rate of 73.33%, and it exhibited resistance to allicin.

Propolis reduces Leishmania amazonensis-induced inflammation in the liver of BALB/c mice.

Experimental models of mouse paw infection with L. amazonensis show an induction of a strong inflammatory response in the skin, and parasitic migration may occur to secondary organs with consequent tissue injury. There are few studies focusing on the resolution of damage in secondary organs caused by Leishmania species-related cutaneous leishmaniasis. We investigated the propolis treatment effect on liver inflammation induced by Leishmania amazonensis infection in the mouse paw. BALB/c mice were infected in the hind paw with L. amazonensis (10(7)) promastigote forms. After 15 days, animals were treated daily with propolis (5 mg/kg), Glucantime (10 mg/kg), or with propolis plus Glucantime combined. After 60 days, mice were euthanized and livers were collected for inflammatory process analysis. Liver microscopic analysis showed that propolis reduced the inflammatory process compared to untreated infected control. There was a decrease of liver myeloperoxidase and N-acetyl-ß-glucosaminidase activity levels, collagen fiber deposition, pro-inflammatory cytokine production, and plasma aspartate transaminase and alanine transaminase levels. Furthermore, propolis treatment enhanced anti-inflammatory cytokine levels and reversed hepatosplenomegaly. Our data demonstrated that daily low doses of Brazilian propolis reduced the secondary chronic inflammatory process in the liver caused by L. amazonensis subcutaneous infection in a susceptible mice strain.

Lymphatic Dissemination in Cutaneous Leishmaniasis Following Local Treatment.

Cutaneous leishmaniasis (CL) is diverse in its clinical presentation but usually demonstrates an erythematous, infiltrated, ulcerated, and crusted papule or nodule in exposed areas of the body. Rare clinical features have been reported including lymphatic dissemination, usually with subcutaneous nodules along lymphatic channels. Herein, we present six patients suffering from Old World CL with lymphatic dissemination characterized by sporotrichoid subcutaneous nodules along the lymphatic channels draining the primary lesion. Patients' history, clinical and laboratory findings were collected and summarized. Lymphatic dissemination of CL in our patients manifested as subcutaneous nodules without epidermal involvement within the axis of lymphatic drainage toward the regional lymph node, at times accompanied by regional lymphadenopathy. In all patients, the lymphatic dissemination was not present at initial diagnosis of CL, appearing only after local (topical or intralesional) treatment was initiated. In three patients, the subcutaneous nodules resolved without systemic treatment. Lymphatic dissemination of Old World CL is not uncommon and may possibly be triggered by local treatment. It should be recognized by dermatologists, especially those working in endemic areas. Systemic treatment may be not necessary since spontaneous resolution may occur.

[Efficacy of pulsed-dye laser on residual red lesions of cutaneous leishmaniasis]. / Efficacité du laser à colorant pulsé sur les lésions résiduelles rouges de la leishmaniose cutanée.

BACKGROUND: Cutaneous leishmaniasis caused by Leishmania tropica can leave troublesome and unsightly lesions. Treatment of these scars remains difficult. Pulsed-dye laser (PDL) is one therapeutic approach that may improve the clinical appearance of erythematosus lesions. The purpose of this retrospective study was to evaluate the effectiveness of PDL on the residual red lesions of erythematous facial leishmaniasis in three patients. PATIENTS AND METHODS: Case no. 1: a 14-year-old girl presented an ulcerative and erythematous nodular lesion on her left cheek. One month after treatment, an erythematous lesion measuring 3 cm persisted on the patient's cheek, without atrophy or hyperpigmentation. PDL 595nm was used at the following settings: duration: 3ms; spot size: 7mm; energy: 8 j/cm(2). Case no. 2: a 43-year-old woman presented an erythematous papular lesion on her right cheek. Following treatment, a 4-cm hypertrophic, red telangiectasic lesion remained. PDL 595nm was used with the following settings: pulse duration: 3 ms; spot-size: 10mm; energy: 8 j/cm(2). Case no. 3: a 60-year-old woman presented an erythematous papular lesion on her cheek. After treatment, an infiltrated erythematous macule with surface telangiectasia measuring 3.5cm remained. PDL 595nm was also given using the following settings: pulse duration: 3 ms; spot size: 10mm; energy: 8 j/cm(2). All three patients underwent three sessions of PDL. The erythematous and telangiectasic lesions showed improvement after the initial session and had completely disappeared after the third session. Post-laser purpura subsided within around 10 days. Therapeutic response was assessed clinically by comparing photographs taken before and after treatment and follow-up lasted 12 months. DISCUSSION: Cutaneous leishmaniasis caused by L. tropica is endemo-epidemic in Morocco. A number of treatments are available for red residual lesions but thanks to its effect on erythematous and vascular lesions, PDL has been shown to provide the most reproducibly good results and is the laser method of choice for this type of scar. A recent study of the dermoscopic features of DL identified the presence of vascular patterns in 100% of cases in this infection, which may account for the efficacy of PDL. PDL results in selective thermolysis that destroys small vessels. Our study showed improvement with PDL regarding scar size, pliability, erythema and texture. Further larger-scale studies could better determine the place of PDL in treating the sequelae of cutaneous leishmaniasis.

Modulation of inflammation response to murine cutaneous Leishmaniasis by homeopathic medicines: Antimonium crudum 30cH.

BACKGROUND: Leishmaniasis is a zoonotic disease caused by protozoan parasites of the mononuclear phagocytic system. The modulation activity of these cells can interfere in the host/parasite relationship and influences the prognosis. METHODS: We evaluated the effects of the homeopathic preparation Antimonium crudum 30cH on experimental infection induced by Leishmania (L.) amazonensis. Male Balb/c mice were inoculated with 2 × 10(6)Leishmania (L.) amazonensis promastigotes into the footpad and, after 48 h (acute phase) or 60 days (chronic phase), cell population of lymphocytes and phagocytes present in the peritoneal washing fluid and spleen were analyzed by flow cytometry and histopathology, with histometry of the subcutaneous primary lesion, local lymph node and spleen. Immunohistochemistry was performed to quantify CD3 (T lymphocyte), CD45RA (B lymphocyte) and CD11b (phagocytes) positive cells. RESULTS: In treated mice, during the acute phase, there was significant increase of the macroscopic lesion, associated to inflammatory edema, as well increase in the number of free amastigotes and B lymphocytes inside the lesion. Increase of B lymphocytes (predominantly B-2 cells) was also seen in the local lymph node, spleen and peritoneum. In the chronic phase, the inflammatory process in the infection focus was reduced, with reduced phagocyte migration and peritoneal increase of B-1a cells (precursors of B-2 immunoglobulin producers cells) and T CD8+ cells. CONCLUSION: The treatment of mice with Antimonium crudum 30cH induced a predominantly B cell pattern of immune response in Leishmania (L.) amazonensis experimental infection, alongside the increase of free amastigote forms number in the infection site. The clinical significance of this study is discussed, further studies are suggested.

Accelerated healing of cutaneous leishmaniasis in non-healing BALB/c mice using water soluble amphotericin B-polymethacrylic acid.

Cutaneous leishmaniasis (CL) is a neglected tropical disease that causes prominent skin scaring. No water soluble, non-toxic, short course and low cost treatment exists. We developed a new water soluble amphotericin B-polymethacrylic acid (AmB-PMA) using established and scalable chemistries. AmB-PMA was stable for 9 months during storage. In vitro, it was effective against Leishmania spp. promastigotes and amastigote infected macrophages. It was also less toxic and more effective than deoxycholate-AmB, and similar to liposomal AmB. Its in vivo activity was determined in both early and established CL lesion models of Leishmania major infection in genetically susceptible non-healing BALB/c mice. Intradermal AmB-PMA at a total dose of 18 mg of AmB/kg body weight led to rapid parasite killing and lesion healing. No toxicity was seen. No parasite relapse occurred after 80 days follow-up. Histological studies confirmed rapid parasite clearance from macrophages followed by accelerated fibroblast mediated tissue repair, regeneration and cure of the infection. Quantitative mRNA studies of the CL lesions showed that accelerated healing was associated with increased Tumour Necrosis Factor-α and Interferon-γ, and reduced Interleukin-10. These results suggest that a cost-effective AmB-PMA could be used to pharmacologically treat and immuno-therapeutically accelerate the healing of CL lesions.

Evaluation of intralesional 0.2% ciprofloxacin as a treatment for cutaneous leishmaniasis.

Although cutaneous leishmaniasis lesions usually heal spontaneously they cause unsightly scarring. This study evaluated a possible new therapy in 38 patients, with 70 lesions, randomly assigned to intralesional injection of ciprofloxacin (0.2%) or intralesional sodium chloride hypertonic solution (7%). After excluding patients who defaulted on treatment, lesions assigned to sodium chloride treatment (n = 21) were completely healed (with or without scarring) in 76.2% of cases, and, when a scar remained, the scar size was reduced 66.0% compared with the original lesion. Lesions assigned to ciprofloxacin (n = 27) showed an 81.5% healing rate with an average scar size reduction of 68.6%. Intralesional 0.2% ciprofloxacin was as effective as hypertonic saline in the treatment of cutaneous leishmaniasis infection.

[Preliminary evaluation of maggot (Diptera: Calliphoridae) therapy as a potential treatment for leishmaniasis ulcers]. / Evaluación preliminar en un modelo animal de la terapia con larvas de Lucilia sericata para el tratamiento de la leishmaniasis cutánea.

INTRODUCTION: Maggot debridement therapy has been widely used for treating a variety of scarred-over soft-tissue wounds. Published accounts record several illnesses in which treatment with larval therapy has promoted injury healing in conjunction with infection by bacterial pathogens resistant to conventional antibiotics. OBJECTIVE: An initial test of the maggot therapy was developed for cutaneous injuries produced by Leishmania amazonensis. MATERIALS AND METHODS: An experimental design based on an animal model with three replicates in Mesocricetus aureatus (Rodentia: Muridae) was used to evaluate size variation lesion before and after after larval therapy with Lucilia sericata maggots . The criteria used for therapy evaluation were lesion size, maggot application time, and presence or absence of edema and secretions. RESULTS: Effective scarring and wound healing was observed after therapy with L. sericata larvae, i.e. 80% to 100% lesion area reduction after 12 hours. CONCLUSION: The preliminary results suggest that fly maggots of L. sericata have a potential use as natural medical and veterinary alternative therapy for the cutaneous leishmaniasis.

Cutaneous leishmaniasis: therapeutic strategies and future directions.

Cutaneous leishmaniasis is a major tropical infection caused by vector-borne protozoa of the Leishmania species. Disease presentation, clinical course, prognosis and response to therapy is species- and geographic region-dependent. A wide variety of treatment modalities exist for the diverse spectrum of clinical disease. Traditional antileishmanial systemic agents such as antimonials, pentamidine and amphotericin are limited by toxic side effects, parenteral route of administration and emerging drug resistance. Newer agents such as oral miltefosine have shown efficacy and tolerability. However, use of systemic pharmacotherapies remains limited by their relative high cost in developing countries and despite advances in basic scientific research, there has been little progress in new drug development for what remains a neglected disease afflicting 12 million of the world's poorest population. This article examines the merits of existing and emerging therapies and reasons for variation in therapy response.

Pseudomonas aeruginosa otochondritis complicating localized cutaneous leishmaniasis: prevention of mutilation by early antibiotic therapy.

A patient with an ulcerated cutaneous leishmaniasis of the pinna had suppurative otochondritis after a first unsuccessful course of treatment with meglumine antimoniate. Although the Leishmania ulceration healed after a second course of meglumine antimoniate, and despite three oral dicloxacillin or pristinamycin courses, the otochondritis extended and an abscess developed. Pus from the abscess revealed a pure culture of Pseudomonas aeruginosa. Five days of oral ciprofloxacin plus rifampin led to a marked improvement. The P. aeruginosa isolate was sensitive to ciprofloxacin but fully resistant to rifampin. Healing with minimal mutilation was obtained at the end of a six-week course of multiple antibiotic therapy. Pseudomonas aeruginosa otochondritis was a co-factor of cartilage mutilation in this patient. Thus, infection with P. aeruginosa should be promptly treated when present in tender cutaneous or mucosal leishmaniasis lesions near cartilaginous areas.

Erysipeloid cutaneous leishmaniasis: treatment with a new, topical, pure herbal extract.

Fourteen consecutive cases of erysipeloid cutaneous leishmaniasis were seen and evaluated. There were 13 females and one male patient with a mean age of 59 years. Diagnosis was based on clinical grounds and the presence of amastigotes in the lesions. Patients were divided into acute and chronic groups, with chronicity being defined as a disease duration of more than a year. All cases were treated with a fresh preparation of a herbal mixture, namely "Z-HE". The paste was applied once daily for 5 consecutive days and thereafter every 2 weeks, as needed, for a maximum period of 3 months. Two patients didn't appear for their regular follow up, the remaining 12 cases were followed up for more than a year after termination of therapy. Eleven (92%) of patients had complete healing in a matter of 1 to 7 months with no relapse after 12 months of follow up. In spite of a successful initial clinical response, the remaining one patient with the acute type of ECL had a subsequent relapse. Otherwise the acute and chronic cases had similar responses to therapy and outcome. No drug related side effect was noted. The high success rate, low cost, ease of preparation, and lack of toxicity makes "Z-HE" a promising new drug. Further investigations are needed to illuminate its mechanism(s) of action and also controlled trials are recommended to confirm its efficacy.

Leishmania major: bacterial contamination of cutaneous lesions in experimental animals.

No bacterial contamination has been demonstrated in cutaneous leishmaniasis (CL) nodule and in lesions caused by Leishmania major in Balb/c mice up to 20 days after infection. However, although many phagocytic cells (polymorphonuclear leukocytes and macrophages) were present in the CL lesion, 80% of the lesions showed bacterial contamination that developed within the first 70 days of infection. Topical treatment of the lesion with an ointment containing 15% paromomycin and 12% methylbenzethonium chloride in soft white paraffin for 20 days eliminated all the Leishmania parasites and several of the associated bacteria including: Proteus vulgaris, Pasteurella multocida, Staphylococcus albus and Staphylococcus aureus. This treatment did not affect Escherichia coli, Klebsiella spp. and Pseudomonas aeruginosa. Total elimination of these bacteria was achieved only during the healing process, and within 20 days following termination of treatment. The rate of disappearance of bacteria inoculated alone into the base of the tail of normal uninfected Balb/c mice was much faster than that of bacteria inoculated into either the CL nodule or the CL lesion. This study suggests the development of local immunosuppression in the CL lesion that may be mediated by the Leishmania parasites and their metabolites.