Correspondence
Fluconazole for the Treatment of Cutaneous Leishmaniasis
N Engl J Med 2002; 347:370-371August 1, 2002
- Article
To the Editor:
Alrajhi et al. (March 21 issue)1 report on the efficacy of systemic fluconazole for Old World cutaneous leishmaniasis caused by Leishmania major. Although this therapy was more efficacious than placebo, the rationale for the study is questionable. Because of potential side effects and high costs, it is unlikely that any systemic therapy will ever become the first-choice therapy for uncomplicated Old World cutaneous leishmaniasis, which is a self-limited skin disease that is usually amenable to topical treatments. Moreover, the cost of six weeks of treatment with fluconazole at a dose of 200 mg per day is about $550. It would be more useful to evaluate the efficacy of fluconazole in patients with no response to topical therapy.
Currently, ointment containing 15 percent paromomycin (Leshcutan, Teva Pharmaceutical) is the treatment of choice for Old World cutaneous leishmaniasis in Israel (where L. major is also the most common pathogen). This treatment results in a cure rate of 76 to 86 percent after a single two-week course of daily topical application.2,3 Promising results have also been reported with topical amphotericin B therapy.4
4 ReferencesAlex Zvulunov, M.D.
Joseftal Hospital, Eilat 88000, Israel
azvulun@bgumail.bgu. ac. il Sidney Klaus, M.D.
Dartmouth–Hitchcock Medical Center, Lebanon, NH 03756Daniel Vardy, M.D.
Ben-Gurion University of the Negev, Beer Sheva 84104, Israel1
Alrajhi AA ,Ibrahim EA ,De Vol EB ,Khairat M ,Faris RM ,Maguire JH . Fluconazole for the treatment of cutaneous leishmaniasis caused by Leishmania major. N Engl J Med 2002;346:891-895
Full Text | Web of Science | Medline2
El-On J ,Livshin R ,Even-Paz Z ,Hamburger D ,Weinrauch L . Topical treatment of cutaneous leishmaniasis. J Invest Dermatol 1986;87:284-288
CrossRef | Web of Science | Medline3
el-On J ,Halevy S ,Grunwald MH ,Weinrauch L . Topical treatment of Old World cutaneous leishmaniasis caused by Leishmania major: a double-blind control study. J Am Acad Dermatol 1992;27:227-231
CrossRef | Web of Science | Medline4
Vardy D ,Barenholz Y ,Cohen R , et al. Topical amphotericin B for cutaneous leishmaniasis. Arch Dermatol 1999;135:856-857
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We agree with Zvulunov et al. that an efficacious, well-tolerated topical agent for the treatment of cutaneous leishmaniasis is highly desirable, particularly for persons with small numbers of lesions on parts of the body other than the face. Although el-On et al.1 reported successful treatment of lesions caused by L. major with topical paromomycin, randomized trials in four different countries demonstrated that the efficacy of this treatment was poor.2-5 Topical paromomycin is currently not available in Saudi Arabia. We do not agree that adverse effects of systemic fluconazole, which were minimal in our study and in other studies, should discourage the evaluation of new indications for its use, including cutaneous leishmaniasis due to L. major outside of Saudi Arabia. The cost of fluconazole is high, but there may be a drop in the price in the near future, particularly when the patent on the drug expires.
5 ReferencesAbdulrahman A. Alrajhi, M.D., M.P.H.
Edward B. De Vol, Ph.D.
King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi ArabiaJames H. Maguire, M.D., M.P.H.
Centers for Disease Control and Prevention, Atlanta, GA 303411
el-On J ,Halevy S ,Grunwald MH ,Weinrauch L . Topical treatment of Old World cutaneous leishmaniasis caused by Leishmania major: a double-blind control study. J Am Acad Dermatol 1992;27:227-231
CrossRef | Web of Science | Medline2
Ozgoztasi O ,Baydar I . A randomized clinical trial of topical paromomycin versus oral ketoconazole for treating cutaneous leishmaniasis in Turkey. Int J Dermatol 1997;36:61-63
CrossRef | Web of Science | Medline3
el-Safi SH ,Murphy AG ,Bryceson AD ,Neal RA . A double-blind clinical trial of the treatment of cutaneous leishmaniasis with paromomycin ointment. Trans R Soc Trop Med Hyg 1990;84:690-691
CrossRef | Web of Science | Medline4
Asilian A ,Jalayer T ,Whitworth JA ,Ghasemi RL ,Nilforooshzadeh M ,Olliaro P . A randomized, placebo-controlled trial of a two-week regimen of aminosidine (paromomycin) ointment for treatment of cutaneous leishmaniasis in Iran. Am J Trop Med Hyg 1995;53:648-651
Web of Science | Medline5
Ben Salah A ,Zakraoui H ,Zaatour A , et al. A randomized, placebo-controlled trial in Tunisia treating cutaneous leishmaniasis with paromomycin ointment. Am J Trop Med Hyg 1995;53:162-166
Web of Science | Medline
- Citing Articles (4)
Citing Articles
1
Mark J. DiNubile. (2008) Nodular lymphangitis: A distinctive clinical entity with finite etiologies. Current Infectious Disease Reports 10:5, 404-410
CrossRef2
M. Rafaa, S. Ingen-Housz-Oro, L. Méry, F. Le Turdu, J. Wendling, C. Pauwels, M. Sigal-Grinberg. (2007) Traitement par fluconazole de la leishmaniose cutanée chez l’enfant. Annales de Dermatologie et de Vénéréologie 134:8-9, 682-683
CrossRef3
Lamya Alnaim, Nermeen Abou Alsoud, Iman Zaghloul, May AL-Jaser. (2007) Effects of fluconazole on the pharmacokinetics and pharmacodynamics of antimony in cutaneous leishmaniasis-infected hamsters. International Journal of Antimicrobial Agents 29:6, 728-732
CrossRef4
Oliver Kayser, Albrecht F Kiderlen. (2003) Delivery strategies for antiparasitics. Expert Opinion on Investigational Drugs 12:2, 197-207
CrossRef
