Dermatology Online Journal

Carbon dioxide laser for the treatment of lupoid cutaneous leishmaniasis (LCL): A case series of 24 patients
Ali Asilian MD, Fariba Iraji MD, Hamid Reza Hedaiti MD, Amir Hossein Siadat MD, Shahla Enshaieh MD
Dermatology Online Journal 12 (2): 3

Department of dermatology, Skin Diseases and Leishmaniasis Research Center, Isfahan University School of Medicine, Iran.

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Abstract

We report the use of a carbon dioxide laser to vaporize local cutaneous leishmaniasis. We used CO₂ laser for the treatment of 24 patients with lupoid cutaneous leishmaniasis in Isfahan. We identified 24 patients with lupoid cutaneous leishmaniasis (LCL) for evaluation. All of the patients had clinical signs of LCL and had the lesion for more than 1 year. LCL diagnosis was confirmed by both direct smear and biopsy. The efficacy of laser was determined on the basis of cure and lack of relapse after 1 year. Treatment was performed using a CO₂ laser (Lasersonic LS500 machine). The maximum power was 100 Watts and the pulse width was 0.5-5 seconds. There were 21 patients, 13 females and 8 males, who were treated and followed for 1 year. Mean duration of the lesions was 4.1± 3.9 years. The treatment was well tolerated and complications were minimal, and included pain, xerosis, and mild erythema. Of these patients, 19 were disease free (90.47 % efficacy based on clinic and laboratory). Only 2 patients were treatment failures (9.5 %). Our results indicate that CO₂ laser radiation is highly effective for treatment of lupoid cutaneous leishmaniasis.

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Introduction

Leishmaniasis is a protozoal disease that is endemic in developing countries. The incidence of leishmaniasis is more than 400,000 cases annually and the prevalence of all forms of leishmaniasis is more than 12 million [1]. Although cutaneous leishmaniasis (CL) is self-healing, the duration of the disease is long and CL requires several months (and sometimes years) before complete recovery, depending on the species of the infecting parasite. After recovery, a disfiguring scar can remain, and there may be destruction of the underlying structures such as the nose or ear, or there may be associated psychological suffering [2]. Although it is frequently seen the Middle East, Christopherson first reported lupoid cutaneous leishmaniasis (LCL) in the English literature in 1923 [3]. LCL is a chronic condition that typically follows acute cutaneous leishmaniasis infection. As the acute lesion heals with scaring, new papules and nodules become apparent. The papules have a granulomatous lupoid appearance and are often scaly. They are characteristically present at the margin of the scarred tissue. Most reported cases are associated with Old World strains of leishmaniasis rather than New World strains; Leishmania tropica is the associated agent in the majority of cases.

The incidence of lupoid leishmaniasis following simple acute cutaneous leishmaniasis ranges from 0.5-6.2 percent. LCL is most prevalent in the endemic areas of leishmaniasis, particularly in the Middle East and Afghanistan [4]. Histological features of this condition include well-organized epithelioid granulomas surrounded by lymphocytes. Necrosis, although not typical, may be present in the pathology of LCL. Leishmaniasis amastigotes are frequently absent on microscopy, and culture for leishmaniasis is frequently negative [5]. There is no standardized treatment for this condition; multiple treatments have been reported with varying degrees of success [6]. Treatment options include cryotherapy,topical antimonial compounds, and intralesional and systemic pentavalent antimony [7].

The use of a carbon-dioxide laser to vaporize the local lesions of cutaneous leishmaniasis is reported for 108 patients with CL with an efficacy of 93.7 percent. Treatment was followed by satisfactory esthetic outcomes [7]. In the current study, we evaluated the results of the treatment of LCL with continuous-wave CO₂ laser in Isfahan.

Methods

We selected 24 LCL patients at random. Patients who were received any treatment for LCL in the recent 3 months were excluded. Also, patients who were pregnant or breast feeding were excluded. Informed consent was obtained from all patients or their parents before treatment.

At the time of enrollment, patients received a full physical examination. Age, sex, and the number and description of the lesions were recorded. Diagnosis was confirmed by direct smear of the lesions for presence or absence of leishman bodies. In the case of a negative smear, we performed a punch biopsy from the edge of the lesions. Photography was done before and after treatment for all patients.

Lesions were locally anesthetized by injection of 1-2 percent lidocaine. Patients and physicians used protective eyewear during treatment. The lesions and a 2-3 mm surrounding margin were treated with continuous CO₂ laser (continuous emission at 10 Watts). After completing the first emission, the surface of the lesion was cleansed with a soaked gauze, and the lesion received a second irradiation. This procedure was repeated until the ulcer bed turned brown (maximum 3-5 times). As a last step, the surface of the lesion was irradiated entirely from further distance for homeostasis. After completion of the procedure, the ulcer was covered with 2 percent erythromycin ointment

After the procedure the patients were followed every week for 3 weeks, then at 1, 3 , 5, and 12 months. An independent observer evaluated the rate of compliance and recorded all side effects. If there was no sign of active disease in or around of the lesion after 1 year, it was considered to be cured. Any recurrence of the active lesion was regarded as a failure of the treatment. This research was performed in Skin Diseases and Leishmaniasis Research Center and Isfahan University of Medical Sciences Clinics.

Results

Figure 1	Figure 2
Figure 1. LCL on the face of the 10-year-old girl present for 7 years and resistant to conventional therapy.
Figure 2. The same patient 5 months after CO2 laser. There is no sign of active disease or scaring. Only minimal hyperpigmentation is present.

Of the 24 patients with LCL recruited for the study, 21 (13 female and 8 males) returned for followup. There were three patients who, for unknown reasons, did not return and they were excluded from the study. Only seven patients had positive smear for leishman body at the time of study (33.3 %). In addition to clinical appearance and past history of leishmaniasis, we used biopsy specimen to confirm the diagnosis in patients who had negative smears. The mean age of patients was 16.6± 14.8 years (range 5-60 years). The mean duration of lesions before treatment was 4.1± 3.9 years. After 1-3 weeks the laser-induced ulcers were healed with mild side effects including burning, pain, and erythema. They responded very well to topical application of betamethasone valerate 1 percent cream. Out of 21 patients, only two patients (9.5 %) had recurrences of leishmaniasis after 1 year of followup and 19 patients had no sign of recurrences (90.47 % efficacy).

Post inflammatory hyperpigmentation occurred in three patients (14.28 %) and it was treated with hydroquinone 4-percent cream. Hypertrophic scar developed in two patients (9.5 %) and it was treated with intralesional triamcinolone acetonide. The two patients who had recurrences of LCL were considered for other kinds of treatment.

Discussion

The cutaneous lesions in chronic lupoid leishmaniasis resemble those of lupus vulgaris both clinically and histologically. The differential diagnosis of this condition is difficult and may depend on the detection of a few leishmania amastigotes in the histologic sections, the growth of the promastigotes in culture, or the identification of amastigotes by other techniques such as PCR [8].

LCL is usually resistant to the conventional therapies for leishmaniasis, and it may persist and spread slowly for many years [2]. In a literature review, we found no application of CO₂ laser for the treatment of LCL. Continuous wave, super mode 10600nm CO₂ laser can vaporize the local lesions by rapid warming of intra- and extracellular water. On the other hand, CO₂ laser can induce selective thermolysis of the infected tissue without significant injury of the surrounding tissue [10]. With that in mind, we evaluated the efficacy of CO₂ laser for treatment of the LCL in 24 patients.

Babajeve and his colleagues reported the use of CO₂ laser for treatment of acute cutaneous leishmaniasis in 108 patients in Russia. Treatment duration was reduced by 1.5 times in comparison with the other treatments; the cosmetic results were good and all the patients were cured within 15-30 days [7]. Redrigves and his colleagues used this treatment for cutaneous leishmaniasis in Cuba and noticed no recurrence after 2 years [9]. Asilian and his colleagues also used CO₂ laser for acute cutaneous leishmaniasis in Isfahan [10]. The results showed that CO₂ laser is more effective in treating cutaneous leishmaniasis than glucantime (1.12 times), has fewer side effects (4.5 % vs. 24 %), has shorter healing time (1 month vs. 3 months), and can be done in single session [10].

Our results showed that CO₂ laser can be highly effective for treatment of lupoid cutaneous leishmaniasis, a condition often resistant to other treatment modalities. This method of treatment seems to have a few side effects, and those are easily treated. We recommend CO₂ laser for the treatment of the lupoid cutaneous leishmaniasis, although further study with a placebo-controlled trial is suggested.

References

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