Acta Dermato-Venereologica 99-1CompleteContent | Page 16

53 CLINICAL REPORT Fractional Ablative CO 2 Laser Followed by Topical Application of Sodium Stibogluconate for Treatment of Active Cutaneous Leishmaniasis: A Randomized Controlled Trial Ofir ARTZI 1 , Eli SPRECHER 1,2 , Amir KOREN 1 , Joseph N. MEHRABI 3 , Oren KATZ 1 and Yuval HILEROWICZ 1 Department of Dermatology, Tel Aviv Medical Center, 2 Department of Human Molecular Genetics & Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, and 3 Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel 1 Conventional treatment of cutaneous leishmaniasis often leaves permanent scars with frequent psycho- social sequelae. The aim of this study was to compare the efficacy, safety, associated pain and final cosmetic outcome of fractional carbon dioxide (CO 2 ) laser fol- lowed by topical application of sodium stibogluconate vs. sodium stibogluconate injections for the treatment of cutaneous leishmaniasis. A total of 181 lesions (20 patients) were randomly assigned to receive intrale- sional injections of sodium stibogluconate (control group) or fractional CO 2 laser treatment followed by topical application of sodium stibogluconate (study group). The visual analogue scale (VAS) score of the control group was much higher than that of the study group (6.85 vs. 3.5, respectively, p  < 0.001). Both the patients and 2 blinded dermatologists found the final cosmetic outcome to be superior for laser-treated le- sions (p  = 0.001 vs. p  =0.008 for controls). Fractional CO 2 laser treatment followed by topical application of sodium stibogluconate is less painful and leads to a better final cosmetic outcome compared with intrale- sional injections of sodium stibogluconate. Key words: cutaneous leishmaniasis; carbon dioxide; ablative fractional laser; drug delivery. Accepted Oct 3, 2018; Epub ahead of print Oct 3, 2018 Acta Derm Venereol 2019; 99: 53–57. Corr: Ofir Artzi, Department of Dermatology, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv 6423906, Israel. E-mail: [email protected] L eishmaniasis is a parasitic infection affecting mil- lion of patients every year (1) and may manifest with cutaneous, mucocutaneous, and visceral lesions, depending mostly on the Leishmania species and the individual’s immunity (2). Leishmania major and L. tropica are the main species of parasites responsible for cutaneous leishmaniasis (CL) in the Old World (Africa, Asia and Europe), including Israel (3). CL usually deve- lops on exposed parts of the body within a few weeks to several months following the sandfly bite, presenting as an erythematous papule that gradually enlarges in size to become a nodule (1). Multiple lesions may develop. The lesion eventually becomes a crusted ulcer with raised in- durated borders (1). Although it is a self-healing disease, the lesions may persist for months to years, often leaving SIGNIFICANCE Cutaneous leishmaniasis is a parasitic infection that affects millions of people every year (1). Although common treat- ments vary in safety and efficacy, none of them addresses the disfiguring atrophic hypo- or hyper-pigmented post-in- flammatory scars. The current study shows that fractional carbon dioxide (CO 2 )  laser treatment, followed by topical application of sodium stibogluconate, is an effective, safe treatment, which is less painful and results in better final cosmesis compared with the current gold standard, intrale- sional injections of sodium stibogluconate. disfiguring atrophic hypopigmented or hyperpigmented scars. These scars may entail mental and social problems (4), thus, many patients seek treatment to remove them or, at least, to improve their cosmesis. Despite recent advances, optimal treatment of CL remains controversial and depends on the Leishmania species and its predicted drug susceptibility, the size, number and location of the lesions, the availability of appropriate drugs and equipment, and the skills and ex- perience of medical personnel (5). Therapeutic options include topical drug therapies, such as paromomycin and imiquimod 5%. Although relatively easy to use and potentially inexpensive, those treatments are usually reserved for ulcerative lesions of CL, since penetration is limited by intact skin (6). Intralesional injection of pentavalent antimony overcomes this obstacle and, in many places, is considered as first-line therapy for CL (7). A few injections are usually required, but injection- related pain is considered substantial, and pain may decrease patient compliance if treatment is needed for numerous lesions (7). Moreover, sedation might be required if performed on children. Some authorities re- commend avoiding intralesional injection of pentavalent antimony on the face and below the knee due to excess risk of complications (6). Oral systemic therapies, such as azoles, azithromycin, and zinc sulphate, have proven beneficial in several studies, but evidence for efficacy was inconclusive in others (8). Miltefosine is a relatively novel agent that was used mainly for visceral leishma- niasis and is now also used for CL, with proven efficacy in both New World and Old World CL (7). Side-effects include teratogenicity and gastrointestinal symptoms, This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2019 Acta Dermato-Venereologica. doi: 10.2340/00015555-3058 Acta Derm Venereol 2019; 99: 53–57