BEST SKIN SPECIALIST COMPARED THE RESPONSE TO TREATMENT OF CUTANEOUS LEISHMANIASIS WITH INTRALESIONAL CHLOROQUINE VS INTRALESIONAL MEGLUMINE ANTIMONIATE
Best skin specialist provides comparison between response to treatment of cutaneous leishmaniasis with intralesional chloroquine vs intralesional meglumine antimoniate
Rifat Yasmin, Ikramullah Khan, Syed Afaq Ahmad
Background In Pakistan, cutaneous leishmaniasis (CL) is mostly caused by Leishmania major. For simple lesions which are few in number and where there is no risk of disfigurement or joint mobility restriction, topical application or local treatment e.g. intralesional antimony compounds are valuable.
Objective To compare the effect of intralesional chloroquine with meglumine antimoniate in the treatment of CL.
Patients and methods Patients and methods In this quasi experimental study, 60 patients of CL with 1 to 3 lesions and aged >3 years were divided into 2 treatment groups to receive either intralesional chloroquine (treatment group) or meglumine antimoniate (control group). Both drugs were used 1cc per cm2 of lesion, once weekly for 8 weeks (8 injections). 8 more injections were given to those who showed partial response.
Results Both treatments showed 100% response; however, greater number of injections was required with meglumine antimoniate (p<0.05). Both drugs were well tolerated.
Conclusion Intralesional chloroquine appears to be an effective, safe and cheap alternative to meglumine antimoniate in the treatment of CL.
Key words Cutaneous leishmaniasis, intralesional, chloroquine, meglumine antimoniate
Introduction As we enter the new millennium, many important strides have been made in cutaneous leishmaniasis (CL) treatment and control. Paradoxically, however, there are still approximately 1.5 million new cases of CL each year worldwide, with the bulk reported from Afghanistan, Iran, Iraq, Algeria, Saudi Arabia, Peru, and Pakistan. According to the World Health Organization (WHO), leishmaniasis is endemic in 88 countries, with a total of 350 million people at risk. It is believed that worldwide 12 million people are currently infected by leishmaniasis.
Most CL lesions are self limiting and may heal in 1-5 years. In spite of this, treatment is justified in a variety of cases, namely early lesions, multiple lesions, lesions involving cosmetically sensitive sites, mucosal lesions and patients with significant immunosuppression. In addition psychological impact of the disease cannot be ignored. The aims of therapy are twofold, namely clinical healing and disappearance of parasites. The disease still presents a therapeutic problem in several parts of the world. Unfortunately to date there is no safe, simple, cheap and effective ambulatory treatment for CL. Pentavalent antimony compounds, ‘the best drug of a bad bunch’ still remain the mainstay of treatment in the majority of cases. However, these have the disadvantage of both toxicity and clinical resistance in at least 40% of cases in certain regions. Other treatment options are pentamidine given systemically and imidazole compounds.6,7,8 Drugs such as allopurinol, rifampicin, dapsone, chloroquine and nifurtimox have found favor in some studies.9 Cryotherapy and intralesional meglumine antimoniate are also found to have beneficial role.10 Physical methods to control transmission of CL as a preventive measure have also been tried with some success.11 For simple lesions which are few in number and where there is no risk of disfigurement or joint mobility restriction, the treatment options, parenteral antimony compounds, because of their untoward effects, inconvenience and cost, are not recommended. Topical application or local treatment of cutaneous lesions, therefore, would be valuable option. Local therapy is of value if it is simpler to administer and less toxic than systemic ones.
Previously, intralesional sodium stibogluconate and meglumine antimoniate have been used with success but keeping in mind its toxicity, cost and availability other treatment options have been tried. One of these is the use of intralesional chloroquine which has shown very encouraging results. Chloroquine is an antiprotozoal drug primarily used in malaria which has much less side effects and cost as compared to antimony compounds. In a pilot study of 10 patients, intralesional chloroquine showed 100% response. 12 To exploit its therapeutic potential in CL, the trial was carried out on a large scale. The objective of this study was to compare the effect of intralesional chloroquine with intralesional meglumine antimoniate in the treatment of cutaneous leishmaniasis.
Patients and methods This quasi-experimental study was conducted at Department of Dermatology, Pakistan Institute of Medical Sciences, Islamabad. The inclusion criteria for the study were patients with 1 to 3 lesions, age more than 3 years and both genders. Patients were excluded from the study if lesions were larger than 5 cm or if they were already getting any systemic or local antileishmaniasis treatment.
The history and examination findings of patients were noted. Diagnosis was confirmed by staining with Giemsa/Leishman’s stain and histopathological examination of skin lesion biopsy. After confirmation of diagnosis informed consent was taken. Two groups were formed by using random number table. Then intralesional chloroquine was given to 30 patients of group A, while the rest of 30 patients (group B) were given intralesional meglumine antimoniate. Injections were given once a week for 8 weeks i.e. 8 injections. 8 more injections were given to those who showed partial improvement. The dose used for both drugs was 1cc per cm2 of the lesion.
At each follow up patients were examined for clinical improvement of lesions and inquired about any local or systemic side effects. Response to treatment was based on clinical resolution of lesions with residual pigmentation/scarring or without scarring. The data were analyzed by SPSS version 10. Descriptive statistics were used to calculate mean, standard deviation for age and regression in lesion size. Frequencies and percentages were calculated for categorical variables e.g. response to treatment. Chi-square test was used to compare response (categorical variables) while t-test was used to compare numerical variables.