Successful treatment of cutaneous leishmaniasis by photodynamic therapy and cryotherapy

ARTICLE

Auteur(s) : Karel Pizinger, Petra Cetkovska, Denisa Kacerovska, Magda Kumpova

Department of Dermatology and Venereology, Medical Faculty, Charles University and University Hospital, Dr. E. Beneše 13, 305 99 Plzeň, Czech Republic

Cutaneous leishmaniasis (CL) sometimes brings a therapeutic problem. The treatments of Old World cutaneous leishmaniasis include cryotherapy [1], heat therapy, itraconazole [2], pentavalent antimony compounds, amphotericin B and other antimycotic drugs, topical and intralesional application of paramomycin, and in recent years also photodynamic therapy (PDT) [3-5]. Lesions of CL heal spontaneously over several months to 2-3 years, and therapy is not always essential. Nevertheless, treatment is indicated in spreading multiple lesions and when the lesion is located on the face and exposed areas of the extremities.

A 39-year-old man was referred to us with multiple lesions similar to furunculosis, which had occured 3 months previous without healing after topical steroid therapy. He was a keen diver and the lesions developed 4 weeks after his last return from vacation in Croatia. The examination revealed a healthy man with 9 slightly tender nodules and plaques of bright pink-reddish colour, sized 1 to 4 cm on the forearms, neck, and thigh. They periodically developed some blistering on the surface (figure 1A). The diagnosis of cutaneous leishmaniasis was confirmed by a biopsy specimen. Leishmania bodies were present in the macrophages as well as extracellularily. No microorganisms were seen in PAS staining and in sections stained to show acid-fast organisms. A culture was not performed.

The following treatment was introduced: Five lesions were treated with PDT whereas the other 4 lesions were treated with cryotherapy. Before initiation of PDT, the crusts and scales were mechanically removed. Then, 20% ALA in gel (hydrochloride form) was applied on the lesions in a 1 mm thick layer. The areas were covered with an occlusive dressing for 3 hours after which the gel was washed off using 0.9 saline solution. Each lesion was illuminated with non-coherent red light with an emission spectrum of 580 to 680 nm (Medeikonos, Sweden), with a total light dose of 75 J/cm² and a light intensity of 88-123 mW/cm². The PDT procedure was repeated once a week for six-weeks.

The remaining 4 lesions were treated simultaneously with a hand-held liquid nitrogen spray unit. The liquid nitrogen was applied directly on the lesion from a distance of 2-3 cm for a freezing time of 30 seconds and a thaw of 60 seconds. Double freeze-thaw cycle treatment per session was used. The procedure was performed once a week for five weeks in total.

The lesions treated with the PDT method improved after 4 sessions and after 6 sessions they were healed with only minimal pigmentation and minor central scarring (figure 1B). The lesions treated with cryotherapy healed after 5 applications with slight pigmentation and minor scar formation in the centre of the lesions, too (figure 1C). No biopsies from clinically healed skin were performed after completion of the treatment. In a 12 month follow-up period no signs of reccurence occured.

Side effects of PDT were a burning sensation during the illumination, which disappeared several minutes after finishing the illumination. During cryotherapy the patient felt only mild burning. No systemic adverse effects of either method were noted.

Both methods used led to complete healing of all treated lesions. However, there was a slight visible difference in the quality of cosmetic effects: cryotherapy led only to more intensive peripheral hyperpigmentation, as compared to PDT, and unlike PDT, it resulted in somewhat more visible atrophic scarring of the central area. Subjectively, cryotherapy was perceived by the patient as a less painful topical treatment than PDT.

The promising results of the PDT treatment, with only mild local irritation and no systemic toxic side effects, and the excellent cosmetic outcome of the PDT treatment suggest that the PDT might find practical use in cases of CL resistant to other methods of treatment and in esthetically-sensitive parts of the body.

Acknowledgements

References

2 Calvopina M, Gervara AG, Armijos RX, et al. Itraconazole in the treatment of New World mucocutaneous leishmaniasis. Int J Dermatol 2004; 43: 659-63.

3 Gardlo K, Horska Z, Enk CD, et al. Treatment of cutaneous leishmaniasis by photodynamic therapy. J Am Acad Dermatol 2003; 48: 893-6.

4 Davidson RN. Practical guide for treatment of leishmaniasis. Drugs 1998; 56: 1009-18.

5 Enk CD, Fritsch C, Jonas F, et al. Treatment of cutaneous leishmaniasis with photodynamic therapy. Arch Dermatol 2003; 139: 432-4.