Cutaneous Leishmaniasis can cause disfiguration and scarring from satellite lesions, especially in children, as they lack immunity to it. This makes prompt management and treatment extremely important in paediatric leishmaniasis cases.

Indigenous cases of cutaneous leishmaniasis (CL) especially in children are mostly seen in the endemic regions of India, the hot dry North‑West Thar Desert of Rajasthan and in certain regions of Uttaranchal, Himachal Pradesh, and Jammu and Kashmir. 

Leishmaniasis is a parasitic disease caused by the organism 'Leishmania' that spreads through the bite of an infected sandfly. Children are more susceptible because they lack immunity to CL.

Case presentations

Gupta M in the paper titled 'Cutaneous leishmaniasis in children: A case series' and published in the Indian Journal of Paediatric Dermatology, 2018 mentioned case studies of ten children with cutaneous leishmaniasis (CL). As per the clinical criteria proposed by Bari and Rahman the clinical diagnosis of CL was made and this was further confirmed with the demonstration of Leishman–Donovan (LD) bodies in Leishman-stained slit skin smears and hematoxylin and eosin-stained skin biopsy sections.

A single CL lesion was seen in eight patients and two lesions each were seen in two patients. The most common site involved was the face which was affected in eight of the ten patients. Four patients had lesions on their cheeks, and two patients had lesions on their nose, and one patient had a lesion on the eyelid and another patient had one lesion on the lips.

• Nodulo-ulcerative (n = 9) was the most common clinical variant followed by the erythematous and oedematous plaque variant
• Skin lesions varied from a period of 1 to 12 months
• LD bodies were found in five of the patients in whom skin smears were done, whereas on doing skin biopsy in four cases, LD bodies were found in only one of them

Depending on the clinical response, nine of the ten patients in the study were given weekly intralesional sodium stibogluconate (SSG) for 4 to 8 weeks, whereas intramuscular SSG was given to the patient with eyelid lesion at a dose of 20 mg/kg/day for 3 weeks.

Management of cutaneous leishmaniasis

1. Pentavalent antimonial compounds or SSG have been recommended by WHO as the most effective treatment at a dose of mg/kg/day over 3 weeks.
2. To avoid toxicity related to systemic administration of antimonials among the paediatric population, intralesional treatment can be considered as a better form of CL treatment.
3. 20% paromomycin ointment, cryotherapy, liposomal amphotericin B, and oral antifungals are the other methods of treatment.

Epidemiological studies have shown that CL cases are more prevalent in childhood and so they are at greater risk of developing the disease as compared to adults. The manifestations of CL are mainly seen on bare/exposed body parts like the face, neck, hands, feet and forearms. The face is the most insecure and exposed area in children, and also the most favorable place for sand-fly to bite as it is an atypical site specifically the eyelids.

When a leismania parasite inoculates the dermis, it is ingested by the dermal macrophages. Further replication of the parasite occurs inside the dermal macrophages only. At the site of the bite, a raised red shiny lesion emerges after an incubation period of 2 to 4 weeks. The lesion either ulcerates and become secondarily infected, or often spontaneously heals with atrophic scarring (L. major).

After healing of the primary lesion (L. viannia braziliensis), there may be a re-appearance of lesions called satellite lesions. CL can cause cosmetic disfiguration, persistence and spread into the mucocutaneous form that can lead to a rise in treatment cost and chances of side effects caused by the existing drugs. To prevent these obstacles, treatment is recommended specifically in children.

1. The pentavalent antimonial compounds are still considered as the mainstay of the treatment for cutaneous leishmaniasis.
2. Alternative therapeutic choices such as the pentamidines and liposomal Amphotericin B can be taken into consideration due to high toxicity related with this group and the current emergence of drug resistant strains.A combination therapy using L-AmB and miltefosine is the most effective substitute for antimonials.
3. In the near future photodynamic therapy, imiquimod, and tamoxifen can show promising results.
4. Miltefosine alone or in combination with the antimonials and L-AmB is proved efficacious in immunocompromised individuals.

Based on the geographic location, availability of the drug, host immune status and expertise of the treating physician, the choice of anti-leishmanial therapy is made. These current methods of treatments are available at specialised centers and hospitals but not at PHC.