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Abstract
There are many parasitic infections of medical importance, which can produce both systemic disease as well as skin lesions. For the most part, treatment of these infections in the elderly does not differ very much from that of younger patients. However, one must be aware that the geriatric population can present with certain challenges with regard to diagnosis of these diseases because history taking may be more difficult and patients often already have a set of other medical problems, which may overshadow the skin lesions. In addition, the clinical manifestations of these infections may not appear classical and may be altered. Dosages of drugs used to treat these infections, even topical agents, may require adjustments in this population. The recognition of scabies in elderly people living together is important and early treatment with topical scabiecides, including oral ivermectin, will help to control the spread of the infestation. Pediculosis may be a cause of pruritus in the elderly and can be treated with malathione, lindane or permethrin. Less common parasitic infections in the elderly, including cutaneous larva migrans and cutaneous leishmaniasis, present with a characteristic clinical picture and can be effectively treated with oral thiabendazole and intravenous antimonials.
... Actually nobody immune to parasitic infection. The type of commonly found parasitic infections of the elderly actually affecting the skin and or the intestinal [5][6][7][8]. Due to previously mentioned factors that make the elderly more prone to parasitic infection, it seems some parasitic agents having more privilege to make infection in certain areas of the elderly body, and they seems to be hypervirulent when attacking the elderly population [7][8][9][10][11]. ...
... The type of commonly found parasitic infections of the elderly actually affecting the skin and or the intestinal [5][6][7][8]. Due to previously mentioned factors that make the elderly more prone to parasitic infection, it seems some parasitic agents having more privilege to make infection in certain areas of the elderly body, and they seems to be hypervirulent when attacking the elderly population [7][8][9][10][11]. ...
... Besides intestinal parasites, skin parasitic infections also commonly found. Scabies, a skin infestation with the mite Sarcoptes scabiei, is often intensely pruritic and distressing [8]. Other parasitic infection of the skin commonly found in the elderly were pediculosis caused by Pediculus humanus capitis et corporis, or superficial fungal infection e.g Dermatophytes [8,9]. ...
The number of the elderly is increasing globally, and as a consequence the number of geriatric health problems also increased, including parasitic infection. The skin and the GI tract were among the most common locations of parasitic infections of the elderly. Underlying biological and social problems can prevent their independence in maintaning basic personal hygiene which made them depend on other's help, permanently. These seniors sometimes become the permanent residence of nursing homes. their dependence made them attached very close to the staff or other helper, even maintaining the basic function of life like eating. If this helper actually a parasitic agent carrier, parasitic infection transmission will be made easy by this symbiotic relationship. Besides behavior, some biological factors, e.g immunosenescence and or organ dysfunction, may contribute to infection.
... Sometimes the itching may be brushed aside, and they are labeled as having psychological itching. 56 Norwegian scabies may be seen in the elderly who are unable to scratch due to some neurological disorder with skin anesthesia or those who are unable to scratch due to physical limitations. 57 The presentation may mimic eczema, and the delay in diagnosis may lead to an outbreak of scabies in nursing homes. ...
Geriatric dermatoses are a challenging job for the physician in terms of diagnosis, management, and followup. Since skin of the elderly population is going through a lot of changes from both an intrinsic and extrinsic point of view, it is imperative for the physician to have a better understanding of the pathophysiology of geriatric skin disorders and their specific management, which differs slightly from an adult population. This review focuses on a brief introduction to the pathophysiological aspects of skin disorders in elderly, the description of some common geriatric skin disorders and their management and the new emerging role of psychodermatological aspects of geriatric dermatoses is also discussed. At the end, ten multiple choice questions are also added to further enhance the knowledge base of the readers.
... [8] may also be difficult for the elderly patient. [3] 2 ...
The scabies mite is an ectoparasite able to infest humans. Its clinical presentation is typical, although in immunocompromised, mentally retarded and elderly patients the clinical presentation may be altered. Diagnosis may therefore be difficult in such patient groups, who often reside in nursing homes. Because delay in diagnosis may induce rapid spread of the scabies mite, immediate diagnosis and treatment are necessary. Normal scabies (scabies vulgaris) and crusted scabies (scabies crustosa, scabies norvegica), although sometimes difficult to diagnose, especially in the elderly, are fortunately quite easy to treat. However, the elderly patient may experience toxicity from local or systemic scabicidal treatment. Single cases of scabies vulgaris should be treated with permethrin cream because of its outstanding efficacy and favourable adverse events profile. Scabies outbreaks and cases of scabies crustosa can easily be managed using combination therapy consisting of topical application of permethrin and two oral doses of ivermectin 200 microg/kg (administered 1 week apart). In addition to treatment of the scabies infestation, preventative measures are necessary, particularly in nursing homes.
Background:
Chronic pruritus (CP), a frequent (20.3%) symptom in the elderly, increases with age. It has a significant impact on the quality of life, ranking among the 50 most burdensome diseases worldwide (Global Burden of Disease Study).
Objectives:
The aim is to provide an overview of the symptom CP in the elderly and to improve differentiation of underlying conditions and management of this entity.
Materials and methods:
A literature search in PubMed was performed, using the terms 'pruritus', 'elderly' and 'gerontodermatology'.
Results:
The main causes of CP in the elderly are the physiologic aging process (xerosis cutis, immunosenescence, neuropathy), the increase in potentially pruritic diseases with increasing age (diabetes mellitus, chronic renal failure), and polypharmacy. Therapeutic options relate to causes, severity of pruritus, and individual patient factors (multimorbidity, impaired organ function). The recently updated S2k guideline 'Diagnosis and therapy of chronic pruritus' is helpful.
Conclusion:
CP in the elderly is challenging for both patients and physicians. Not only the difficulty of identifying the underlying cause, but the complexity of treatment and its tolerability and practicability determines these patients' further burden.
In many regions of the world, Leishmaniasis is a cause of substantial mortality and ailment. Due to impediment in available treatment, development of novel and effective treatments is indispensable. Significance of autophagy has been accentuated in infectious disease as well as in Leishmaniasis, and it is having capability to be manifested as a therapeutic target. By evincing autophagy as a novel therapeutic regime, this study emphasized on the critical role of ATG4.1-ATG8 and ATG5-ATG12 complexes in Leishmania species. The objective here was to identify ATG8 as a potential therapeutic target in Leishmania. R71T, P56E, R18P are the significant mutations which shows detrimental effect on ATG8 while Arg276, Arg73, Cys75 of ATG4.1 and Val88, Pro89, Glu116, Asn117, and Gly120 are interacting residues of ATG8. Along with this, we also bring into spotlight an enticing role of Thiabendazole derivatives that interferes with the survival mechanisms by targeting ATG8. Further, the study claims that thiabendazole can be a potential drug candidate to target autophagy process in the infectious disease Leishmaniasis.
Die Skabies ist eine häufige Ektoparasitose, deren Prävalenz hierzulande offenbar auch bei alten Menschen zunimmt. Aufgrund des nicht selten atypischen klinischen Erscheinungsbildes, des mitunter fehlenden Juckreizes und vieler Differenzialdiagnosen ist die Diagnose in dieser Altersgruppe erschwert. Von besonderer Bedeutung ist die milbenreiche und daher hochkontagiöse Scabies crustosa, die überwiegend bei immunsupprimierten Patienten sowie Menschen mit geistiger und körperlicher Behinderung vorkommt und von der Ausbrüche in Altenheimen und Pflegeeinrichtungen oft ihren Ausgang nehmen. Im vorliegenden Beitrag werden Diagnostik und Therapie der Skabies sowie das Vorgehen in Ausbruchsituationen unter besonderer Berücksichtigung alter Patienten dargestellt.
The goals of this German guideline are the improvement of diagnosis and therapy of scabies, the implementation of a coordinated action in outbreaks of scabies, and the control of this infestation in large migration or refugee flows.Sarcoptes scabiei var. hominis is transmitted by direct skin-to-skin contact of sufficient duration. The infectivity of female mites when removed from patients does not exceed 48 hours at room temperature (21°C) and relative humidity of 40-80%. The risk of infection rises proportionally to the number of mites on the skin and is particularly high in crusted scabies. As elderly persons tend to develop crusted scabies due to disease- or medication-related immunosuppression, there is an increased risk for outbreaks of scabies at nursing homes and extended-care facilities. The guideline contains detailed recommendations for management of such outbreaks. In refugees the prevalence of scabies is higher than in the general population in Germany, but the risk for outbreaks is not high. Scabies infestation should be considered when a recent onset of itching is associated with eczema and presence of burrows or comma-like papules at predilection sites. It is confirmed by dermatoscopic detection of mites or by microscopic identification of mites, mite eggs or fecal matter (scybala) from skin scrapings.The treatment of choice for common scabies is topical permethrin 5% cream applied for 8-12 hours. Permethrin can be considered for off-label use also in infants of less than 3 months of age and pregnant women. For this group crotamiton is another option, which, besides benzyl benzoate, presents a good second line therapy for the other indications. Indications for oral ivermectin, which has just been licensed in Germany, include patients with immunosuppression, severe dermatitis, and low adherence.Crusted scabies is preferentially treated by a combination of topical permethrin and oral ivermectin. Affected patients should be isolated, and all contact persons should be treated. The guideline contains lists for additional measures, including possible treatment of contact persons, clothes, linen and other possibly infested articles.
Die durch diverse Bakterien, Pilze und Parasiten hervorgerufenen tropischen Infektionen gehören zu den häufigsten Hautkrankheiten überhaupt. Mehr als 90 Mio. Menschen sind weltweit an einer lymphatischen Filariose erkrankt und über 200 Mio. Menschen an einer Schistosomiasis; bei fast allen diesen Kranken ist die Haut der hauptsächliche Manifestationsort der Infektion. Mit Leishmanien sind ca. 12 Mio. und mit Onchocerca volvulus weit über 18 Mio. Menschen infiziert. Diese Zahlen vermitteln einen Eindruck davon, welche ungeheure Aufgabe und Verantwortung die Dermatologie in den Ländern mit tropischem oder subtropischem Klima heute hat. Durch die Zunahme des Massentourismus ist auch der Dermatologe im europäischen Raum immer wieder mit Erkrankungen dieser Art konfrontiert. Er sollte in der Lage sein, diese zu erkennen und auch die neuen therapeutischen Entwicklungen auf diesem Gebiet zu überblicken.
Cutaneous infections are a common source of morbidity and mortality in the elderly. Various factors, such as waning cellular immunity, immunosuppression, and/or comorbid conditions, make the older person susceptible to infectious diseases. Examples include certain viral diseases (herpes zoster, herpes simplex), fungal (tinea pedis, onychomycosis) and yeast infections (intertrigo), bacterial infections (cellulitis, erypsipelas, folliculitis, furunculosis), and certain infestations (scabies). With early diagnosis and treatment, most of these infections resolve without sequelae.
The skin of older adults undergoes intrinsic aging and is susceptible to multiple ailments. Both comorbidities and environmental issues increase the risk for particular skin diseases among older adults who live in long-term care facilities. This article looks at four common skin conditions frequently found among older adults living in long-term care facilities, and reviews methods of treatment and prevention.
Infectious skin diseases caused either by bacteria, fungi or viruses, account for an important burden in dermatology practice. The number is increasing due to higher percentage of immunocompromised patients. Although in many instances they can be successfully treated with topical agents, sometimes systemic antimicrobial agents are indicated. This occurs in extensive or complicated skin and soft tissue infections, tinea capitis, onychomycosis, genital herpes or herpes zoster. Besides, some antibacterial agents have been shown to have antiinflammatory properties and they have been successfully used for the treatment of noninfectious skin diseases. New drugs are continuously developing due to increasing multi-drugs resistant microorganisms, especially in the context of immunocompromised patients. Appropriate antimicrobial selection requires the consideration of multiple factors, including conditions of the host, the disease and the drug. Clinicians should know the properties, indications and adverse events related to the old and new antimicrobial agents in order to choose the correct option.This chapter summarizes the characteristics of systemic antimicrobial agents commonly used in dermatology.
Scabies is a global problem and a significant source of morbidity in nursing home residents and workers because of its highly contagious nature. It is also a problem in hospitals that care for the elderly, the debilitated, and the immunocompromised. New outbreaks continue to occur, despite controlling the recurrent epidemics. Scabies manifests as papules, pustules, burrows, nodules, and occasionally urticarial papules and plaques. Most of the patients with scabies experience severe pruritus. A subset of patients have crusted or Norwegian scabies. These patients, who are usually debilitated or immunocompromised, do not experience the urge to scratch, and therefore do not scratch their own skin. Diagnosis of scabies is based on patient history, physical examination, and demonstration of mites, eggs, or scybala (black or brown football-shaped masses of feces of scabies) on microscopic examination.
Scabies can be treated with topical or oral therapies. Topical treatments include 5% permethrin cream, 1% lindane (gamma benzene hexachloride) lotion, 6% precipitated sulfur in petrolatum, crotamiton, malathion, allethrin spray, and benzyl benzoate. Ivermectin, the only oral treatment, is not approved for scabies in the US. Most authorities advocate using a scabicide several times, specifically once a week over a period of 2–3 weeks. In an outbreak of scabies in a nursing home, residents, staff, and frequent visitors should all be treated even if they are not symptomatic. Ivermectin is useful in treating patients with Norwegian or crusted scabies, or who are debilitated. Ivermectin has no serious reported adverse effects. Model treatment plans to stop scabies epidemics have been developed. These plans coordinate treatment of all persons exposed (including ivermectin for debilitated patients), isolation of infected patients, disinfection of objects that patients have come into contact with, and education and reassurance of the medical staff. Failure to coordinate notification, education, treatment, and disinfection leads to failure to control scabies epidemics. Control of epidemics of institutional scabies requires attention to treatment effects and logistics. Treatment is low risk, but cumbersome because many individuals need be treated. It is advisable to restrict, where possible, the number of staff members that deal with scabies patients to limit the spread of the scabies. Prolonged surveillance is required for the eradication of institutional scabies. While the foregoing plans require coordination of all involved personnel and sustained efforts, they are necessary to halt the spread of scabies to patients and staff, to enhance their morale, and to prevent deterioration of labor and public relations.
Human skin is a visible indicator of age. Structural and physiological changes that occur intrinsically with ageing skin combined with the effects of cumulative extrinsic damage can result in a marked susceptibility to cutaneous disorders in older patients. The progressive degeneration of ageing skin results in atrophy of the vasculature, deterioration of supporting dermis and erosion of normal immune function. Changes from the intrinsic and extrinsic effects of ageing skin have a wide clinical expression, e.g. xerosis, eczema, seborrheic dermatitis and contact dermatitis. Although rarely fatal, these cutaneous disorders can cause morbidity and reduce quality of life. Primary skin malignancies resulting from cumulative solar damage also carry considerable mortality. There have been exciting advances in the diagnosis and treatment of skin diseases in older people. However, comorbidities, polypharmacy and altered pharmacokinetics seen in older people pose significant challenges to effective treatment. Managing skin disorders in older people is often less than optimal because their special needs and limitations are not adequately addressed. This review provides an overview of treatments available for managing skin conditions commonly encountered in older people.
Leishmaniasis encompasses a group of chronic infections caused by over 20 species of Leishmania genus. It is transmitted by sandflies between animal and human hosts and accounts for a complicated health problem in endemic areas of often developing countries. 1. The elderly have specific health characteristics: alterations in immune system2, hormonal changes3, altered attention to illness and treatment, irregular and multiple drug consumption, comorbidities, and different disease presentations.4, 5This article is protected by copyright. All rights reserved.
Topical antiscabietics have poor compliance. This study aimed at comparing the efficacy and safety of oral ivermectin with topical lindane in treating scabies. In this clinical trial, 248 patients from 2 to 86 years of age were divided into two groups. Oral ivermectin was given to group A in a single dose of 200 μg/kg body weight. Group B received application of lindane lotion 1% twice at one-week interval. When there was no cure in two weeks, 2nd treatment was given with either drug in the respective group. A single dose of ivermectin provided a cure rate of 58.6% at two-week follow up, which increased to 92.7% with 2 doses at the end of 4-week interval. The application of lindane lotion 1% twice at one-week interval was effective in 44.3% of patients at two-week follow up, which increased to 71.7% after repeating the treatment for another two weeks. Single dose application of oral ivermectin was as effective as twice application of lindane lotion 1% at one-week interval. Two doses of ivermectin proved superior to lindane lotion 1% after repeating the treatment at 4-week follow up.
To review the use of the oral antiparasitic ivermectin in the treatment of scabies, with an emphasis on its use in the elderly and in long-term care settings.
A MEDLINE/PUBMED search was conducted to identify pertinent studies, case reports, letters, and reviews in the English language. All articles published from 1980 to October 2003 were reviewed. Additional references were obtained from the bibliographies of these articles.
All studies evaluating ivermectin in the context of scabies mite infestation.
The semisynthetic macrocyclic lactone ivermectin has been available since the early 1980s as a broad-spectrum antiparasitic agent in animals and humans. This agent, which works by suppressing motor nerve conduction leading to parasite paralysis and death, was first used in ectoparasitic diseases (i.e., those caused by lice and mites) shortly after commercial introduction. A large body of literature, mainly uncontrolled case reports and series, has since evolved. However, these reports and results of the small number of placebo- and/or active-controlled studies have demonstrated the favorable response of both classic and crusted scabies to single- and multiple-dose oral ivermectin. Adverse reactions to the drug are uncommon, with the exception of a transient, new onset, or mild increase in existing pruritus soon after drug ingestion, which is thought to be a hypersensitivity reaction to dead mites and/or their products.
Oral ivermectin may prove to be a time- and labor-saving alternative to topical scabicide treatments, especially in the institutional setting where labor shortages make the management of scabies outbreaks a true challenge. However, the use of this agent does not change the need to decontaminate the environment (clothing, bedding, bed clothes, and, in selected cases, floors and walls) in order to truncate an outbreak and prevent reinfestation.
Scabies is a global problem and a significant source of morbidity in nursing home residents and workers because of its highly contagious nature. It is also a problem in hospitals that care for the elderly, the debilitated, and the immunocompromised. New outbreaks continue to occur, despite controlling the recurrent epidemics. Scabies manifests as papules, pustules, burrows, nodules, and occasionally urticarial papules and plaques. Most of the patients with scabies experience severe pruritus. A subset of patients have crusted or Norwegian scabies. These patients, who are usually debilitated or immunocompromised, do not experience the urge to scratch, and therefore do not scratch their own skin. Diagnosis of scabies is based on patient history, physical examination, and demonstration of mites, eggs, or scybala (black or brown football-shaped masses of feces of scabies) on microscopic examination. Scabies can be treated with topical or oral therapies. Topical treatments include 5% permethrin cream, 1% lindane (gamma benzene hexachloride) lotion, 6% precipitated sulfur in petrolatum, crotamiton, malathion, allethrin spray, and benzyl benzoate. Ivermectin, the only oral treatment, is not approved for scabies in the US. Most authorities advocate using a scabicide several times, specifically once a week over a period of 2-3 weeks. In an outbreak of scabies in a nursing home, residents, staff, and frequent visitors should all be treated even if they are not symptomatic. Ivermectin is useful in treating patients with Norwegian or crusted scabies, or who are debilitated. Ivermectin has no serious reported adverse effects. Model treatment plans to stop scabies epidemics have been developed. These plans coordinate treatment of all persons exposed (including ivermectin for debilitated patients), isolation of infected patients, disinfection of objects that patients have come into contact with, and education and reassurance of the medical staff. Failure to coordinate notification, education, treatment, and disinfection leads to failure to control scabies epidemics. Control of epidemics of institutional scabies requires attention to treatment effects and logistics. Treatment is low risk, but cumbersome because many individuals need be treated. It is advisable to restrict, where possible, the number of staff members that deal with scabies patients to limit the spread of the scabies. Prolonged surveillance is required for the eradication of institutional scabies. While the foregoing plans require coordination of all involved personnel and sustained efforts, they are necessary to halt the spread of scabies to patients and staff, to enhance their morale, and to prevent deterioration of labor and public relations.
Pentavalent antimony, the generally accepted treatment for leishmaniasis, is given parenterally, and it is expensive and not readily available in developing countries. An inexpensive, orally administered compound would be a substantial advance in treatment. Previous studies in vitro have shown synergism between allopurinol and pentavalent antimony in tissue-culture systems. We designed this clinical study to determine whether synergism could be demonstrated in patients.
We performed a randomized, controlled study of the efficacy of allopurinol plus meglumine antimoniate (Glucantime), as compared with meglumine antimoniate alone, in patients with cutaneous leishmaniasis, who were recruited from a village in southeastern Colombia. In addition, those who declined injections were treated with allopurinol alone, and those who declined any treatment were considered controls. All the patients were followed for one year after the completion of treatment. Lesions that healed completely at three months and remained healed during follow-up were considered to be cured.
The cure rate for patients treated with meglumine antimoniate was 36 percent; the addition of allopurinol increased the rate to 74 percent (P less than 0.001). Treatment with allopurinol alone yielded a cure rate of 80 percent (P less than 0.001). There were no cures among the untreated patients. There was no significant difference between the cure rate with allopurinol plus meglumine antimoniate and that with allopurinol alone. No major toxic effects were observed.
For the treatment of American cutaneous leishmaniasis, the combination of allopurinol and meglumine antimoniate is significantly more effective than meglumine antimoniate alone, probably because of the efficacy of allopurinol alone, which appears to be as good as the combination.
Because of the concern for potential neurotoxic effects (central nervous system excitation, convulsions) in the treatment of scabies using 1% lindane lotion, 5% permethrin cream has been suggested as an alternative scabicide. Using the finite dose technique, in vitro percutaneous absorption of 5% permethrin cream or 1% lindane lotion was measured in human and guinea pig skin following a single application. In vivo blood and brain levels of the scabicides were measured in guinea pigs following three daily applications of 5% permethrin cream or 1% lindane lotion. Permethrin and lindane levels were quantified by gas chromatography/mass spectroscopy.
In vitro percutaneous absorption of the two scabicides was identical in guinea pig skin; however, human skin was 20-fold more permeable to lindane than to permethrin. In vivo guinea pig blood and brain levels of lindane were fourfold greater than permethrin levels.
The risk for toxic effects, as assessed by systemic exposure during overuse conditions, is projected to be 40 to 400 times lower for 5% permethrin cream than for 1% lindane lotion.
Ivermectin was used for the treatment of a scabies outbreak in a nursing home. Among the 128 residents, 42 presented pruritus or cutaneous lesions and scabies was parasitologically demonstrated in seven patients. All residents were treated with two 12 mg doses of ivermectin given two weeks apart. Ivermectin treatment associated with procedures for environmental disinfection led to the control of the outbreak. In only one case, was there a failure of the treatment. It is concluded that oral ivermectin is an effective and practical therapy for scabies in nursing homes.
Despite all the available pediculicides and scabicides that have been developed in this century we still find ourselves facing a treatment dilemma. Although body lice are not abundant in the United States, they are still found in the homeless populations of our major cities. With the development of dichlorodiphenyltrichloroethane (DDT) in the early 1940s there was no longer a reason to pursue the basic biology of lice. Cheap and effective treatments such as DDT reduced the lice supply and with them the louse-borne diseases that went with the body louse. These diseases, such as trench fever caused by Bartonella quintana, are re-emerging in the United States and in other countries. Head lice and crab lice have never been studied as possible vectors of disease, because they were not usually found in the same population and because, unlike body lice, no laboratory model for head or crab lice exists. Body lice have given all lice a bad reputation, and the stigma from infestations with lice make education in this area difficult. Much of the older lice studies in the literature were conducted in the cold climate of England, which is quite different from climactic conditions in the United States. Body lice, not head or crab lice, were used because they were hardier and can go longer without a blood meal. Pediculosis capitis infestations are in epidemic proportions in some parts of the United States and the world. The development of lice resistant to DDT, lindane, malathion, and permethrin and with a reduced efficacy with natural pyrethrins has resulted in the highest prevalence of head lice in the last 50 years. Parents are spending hundreds of dollars on head lice products that do not meet their purported claims. Some children in Florida have missed more than 2 months of school because of head lice or nits. Parents and even dermatologists are prescribing anything from petroleum gel to olive oil and mayonnaise in an effort to get children back in school. Oral ivermectin is a promising candidate for resistant lice, but future studies will be needed to determine the optimum dosing regimens. Oral ivermectin has been effective even against crusted cases of scabies in patients with acquired immunodeficiency syndrome. In this monograph the diagnosis and treatments for body, head, and crab lice and scabies are discussed, including issues of resistance and treatment in immunocompromised individuals.
The treatment of 33 cases of diffuse cutaneous leishmaniasis in Ethiopia is presented.
Pentamidine isethionate and amphotericin B have proved the two drugs to which the parasite is consistantly sensitive. Both are seriously toxic and better drugs are needed. Weekly or fortnightly pentamidine at the lowest dose that will produce a response is probably the best treatment; the glucose tolerance test should be performed weekly. Antimonals are usually ineffective but N-methylglucamine antimoniate shows some activity in high, approaching toxic, doses. The apparent effect of chloroquine may be due to its anti-inflammatory properties. Cycloguanil pamoate, primaquine and its analogue 349-C59 and macrocyclon may be useful if given in much higher doses than generally recommended. Toxic effects of these drugs have not so far been encountered.
Relapse almost inevitably follows treatment and can occur repeatedly and up to 15 months later. Treatment must be repeated or prolonged for several months after the apparent elimination of the parasite in order to achieve cure. Before the patient is “cured,” the disease in relapse usually shows a tuberculoid histology and is accompanied by a positive leishmanin test, after which a further course of any effective drug will “cure” him. Without such an immune conversion it is very difficult to cure the patient.
This review summarizes the current knowledge of cutaneous leishmaniasis, a disease affecting millions of people throughout the world. Not only are there still difficulties in diagnosing several of its clinical forms, but also the treatment remains unsatisfactory. In addition, there are many unanswered questions concerning the immunology of this disease, and the need for more research is mandatory if the different strains of the parasite and their life cycles, insect vectors, natural reservoirs and some unknown endemic areas are to be explained.
A controlled study of the efficacy of topical paromomycin sulfate (PR) and methylbenzethonium chloride (MBCl) in cutaneous leishmaniasis (CL) has not yet been performed.
The therapeutic effect of an ointment containing 15% PR and either 12% or 5% MBCl (15/12 or 15/5 P-ointment) on patients suffering from Old World CL was examined in a randomized, double-blind, cross-over study.
Thirty-nine patients with Old World CL caused by Leishmania major were treated topically, twice daily, for 10 to 20 days with 15/12 or 15/5 P-ointment and 10 to 20 days with a placebo ointment to achieve a total of 30 days of treatment in all groups.
In the P-ointment-treated groups, 74.2% (29 of 39 patients) of the patients were cured versus 26.6% (4 of 15 patients) in the placebo-treated group. Little difference was found between the 15/12 and 15/5 P-ointment groups.
In most of the patients treated with the active ingredients, total elimination of the parasites was achieved within the first 10 days of treatment.
The classic agent for cutaneous leishmaniasis is pentavalent antimony. However, there are no reports of the efficacy of antimony versus placebo or of the efficacy of any alternative therapy versus either antimony or placebo. In the present report, the oral antifungal agent ketoconazole (600 mg/day for 28 days) was compared to a recommended regimen of intramuscular Pentostam (20 mg antimony/kg, with a maximum of 850 mg antimony/day, for 20 days) in a randomized study of the treatment of Panamanian cutaneous leishmaniasis due to Leishmania braziliensis panamensis. A separate group of patients with this disease was administered placebo.
Ketoconazole clinically cured 16 of 21 (76%) patients. The lesions on nine patients healed by 1 month after therapy, and the lesions healed by 3 months after therapy on the other seven patients. Side effects were limited to a 27% incidence of mild, reversible hepatocellular enzyme elevation and an asymptomatic, reversible, approximately 70% decrease in serum testosterone in all patients. Pentostam cured 13 of 19 (68%) patients; the lesions on seven patients healed by the end of therapy, and the lesions on four other patients healed by 1 month after the end of therapy. Side effects were a 47% incidence of mild, reversible hepatocellular enzyme elevation and the morbidity due to 20 intramuscular injections in almost all patients. The placebo group of 11 patients had a 0% cure rate. By 1 month after therapy, all placebo-treated patients demonstrated new lesions or one lesion that was 23% to 875% larger than before therapy.
Both ketoconazole and Pentostam were more effective than placebo against L. braziliensis panamensis cutaneous leishmaniasis. Oral ketoconazole is comparable in efficacy to this parenteral Pentostam regimen and can be recommended as initial treatment for this disease.
Scabies and lice have afflicted man since ancient times. Permethrin is generally the treatment of choice for head lice and scabies, because of its residual effect. Toxicity and absorption are minimal. Ivermectin should be reserved for cases where permethrin fails.
The natural course of untreated creeping eruption was studied in a group of 25 patients. The treatment of the disease with oral thiabendazole in another group of 28 patients is also reported. Thiabendazole was observed to significantly shorten the course of creeping eruption. Transient unpleasant side-effects were noted in 13 of the 28 drug-treated patients.
In this paper, Dick Ashford, Philippe Desjeux and Peter deRaadt attempt to estimate the total number of people at risk of acquiring disease caused by infection with Leishmania spp. In many areas a very small risk is distributed among large numbers of people so, although the number of people at risk may be large, the number of infections may be very small. An estimate of the global annual incidence of new cases has also been made. This refers to reported clinical disease and probably grossly underestimates the number of infections. The methods by which the estimates have been made are specified so that they, as well as the estimates themselves, may be criticized and modified with some degree of objectivity.
Diffuse cutaneous leishmanisis
- Adm Bryceson
Death after ivermectin treatment
- R Barkwell
- Shields