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Parhizkar AR, Sharafi M, Mansuri S, Hadibarhaghtalab M, Afrashteh S, Fatemian H, Chijan MR. Comparing the efficacy of fluconazole and cryotherapy Versus cryotherapy alone on treating cutaneous leishmaniasis: a triple-blind randomized clinical trial. BMC Infect Dis 2024; 24:332. [PMID: 38509490 PMCID: PMC10953173 DOI: 10.1186/s12879-024-09211-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 03/11/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVE Cutaneous Leishmaniasis (CL) is one of the highly prevalent endemic diseases in the Middle East. The disease is a complex skin infection imposing a heavy burden on many developing countries. This study aimed to evaluate the impact of adding oral fluconazole to topical cryotherapy on the treatment efficacy and time to achieve complete recovery of CL lesions. METHOD This triple-blind randomized clinical trial included 52 participants with CL. Participants were allocated to receive either weekly cryotherapy with liquid nitrogen and oral fluconazole at a dose of 6 mg/kg daily at a maximum of 400 mg for 6 weeks as the interventional arm or weekly cryotherapy with liquid nitrogen plus the placebo for the same period of 6 weeks as the control arm. RESULTS Fifty-two eligible participants enrolled the study, with a CL lesion count of 1 to 8 (mean 1.96), and served as the interventional (n = 28) and control (n = 24) arms. The trend of the mean surface area of the lesions was significantly decreasing in both arms (P < 0.001), with no statistically significant difference between arms (P = 0.133) or all assessed time point pairwise comparisons (P > 0.05). There was no significant difference between the treatment arms in terms of the end-point recovery status (P = 0.491) or the frequency of post-treatment secretion (P = 0.437). No adverse effect was observed. CONCLUSION Despite a slightly higher reduction in the lesion surface in the cryotherapy and fluconazole treatment arm, the addition of fluconazole did not provide statistically significant therapeutic value to cryotherapy in the treatment of CL. However, with adjustment for the initial lesion size, the efficacy of the regimen in the interventional arm was more pronounced, though it was still insignificant.
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Affiliation(s)
- Ahmad Reza Parhizkar
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Mehdi Sharafi
- Infectious and Tropical Diseases Research Center,Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran.
| | - Susan Mansuri
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Sima Afrashteh
- Department of Biostatistics and Epidemiology, Faculty of Health and Nutrition, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Hossein Fatemian
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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Bamorovat M, Sharifi I, Agha Kuchak Afshari S, Karamoozian A, Tahmouresi A, Heshmatkhah A, Salarkia E, Khosravi A, Hakimi Parizi M, Barghi M. Poor adherence is a major barrier to the proper treatment of cutaneous leishmaniasis: A case-control field assessment in Iran. Int J Parasitol Drugs Drug Resist 2022; 21:21-27. [PMID: 36525935 PMCID: PMC9791244 DOI: 10.1016/j.ijpddr.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
Leishmaniasis is an overlooked, poverty-stricken, and complex disease with growing social and public health problems. In general, leishmaniasis is a curable disease; however, there is an expansion of unresponsive cases to treatment in cutaneous leishmaniasis (CL). One of the effective and ignored determinants in the treatment outcome of CL is poor treatment adherence (PTA). PTA is an overlooked and widespread phenomenon to proper Leishmania treatment. This study aimed to explore the effect of poor adherence in unresponsiveness to treatment in patients with anthroponotic CL (ACL) by comparing conventional statistical modalities and machine learning analyses in Iran. Overall, 190 cases consisting of 50 unresponsive patients (case group), and 140 responsive patients (control group) with ACL were randomly selected. The data collecting form that included 25 queries (Q) was recorded for each case and analyzed by R software and genetic algorithm (GA) approaches. Complex treatment regimens (Q11), cultural and lay views about the disease and therapy (Q8), life stress, hopelessness and negative feelings (Q22), adverse effects of treatment (Q13), and long duration of the lesion (Q12) were the most prevalent significant variables that inhibited effective treatment adherence by the two methods, in decreasing order of significance. In the inherent algorithm approach, similar to the statistical approach, the most significant feature was complex treatment regimens (Q11). Providing essential knowledge about ACL and treatment of patients with chronic diseases and patients with misconceptions about chemical drugs are important issues directly related to the disease's unresponsiveness. Furthermore, early detection of patients to prevent the long duration of the disease and the process of treatment, efforts to minimize side effects of treatment, induction of positive thinking, and giving hope to patients with stress and anxiety by medical staff, and family can help patients adhere to the treatment.
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Affiliation(s)
- Mehdi Bamorovat
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran,Corresponding author. Leishmaniasis Research Center, 22 Bahman Boulevard, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran.
| | - Iraj Sharifi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran,Corresponding author. Leishmaniasis Research Center, 22 Bahman Boulevard, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran.
| | | | - Ali Karamoozian
- Research Center for Modeling in Health, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Amireh Heshmatkhah
- Dadbin Health Clinic, Kerman University of Medical Sciences, Kerman, Iran
| | - Ehsan Salarkia
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Khosravi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Maryam Hakimi Parizi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Maryam Barghi
- Department of Biochemistry, Faculty of Veterinary Medicine, Shiraz University, Shiraz, Iran
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Bamorovat M, Sharifi I, Tavakoli Oliaee R, Jafarzadeh A, Khosravi A. Determinants of Unresponsiveness to Treatment in Cutaneous Leishmaniasis: A Focus on Anthroponotic Form Due to Leishmania tropica. Front Microbiol 2021; 12:638957. [PMID: 34140933 PMCID: PMC8203913 DOI: 10.3389/fmicb.2021.638957] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/19/2021] [Indexed: 12/17/2022] Open
Abstract
Cutaneous leishmaniasis (CL) is a curable disease; however, due to various risk factors, unresponsiveness to CL treatments is inevitable. The treatment of CL has been firmly correlated with multiple determinants, such as demographical, clinical, and environmental factors, the host’s immune response, poor treatment adherence, the parasite’s genetic make-up, and Leishmania RNA virus. This study primarily focuses on the risk factors associated with different therapeutic outcomes following meglumine antimoniate (MA; Glucantime®) treatment and policy approaches to prevent unresponsiveness in CL patients with a focus on anthroponotic form (ACL). Findings suggest that effective preventive and therapeutic measures should be more vigorously implemented, particularly in endemic areas. Accordingly, extensive training is essential to monitor drug unresponsiveness regularly, especially in tropical regions where the disease is prevalent. Since humans are the fundamental reservoir host of ACL due to L. tropica, prompt detection, early diagnosis, and timely and effective treatment could help control this disease. Furthermore, major challenges and gaps remain: efficacious vaccine, new tools, and expert staff are crucial before CL can be definitively controlled.
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Affiliation(s)
- Mehdi Bamorovat
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Iraj Sharifi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Abdollah Jafarzadeh
- Department of Immunology, Medical School, Kerman University of Medical Sciences, Kerman, Iran
| | - Ahmad Khosravi
- Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
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Michelerio A, Barruscotti S, Bossi G, Brazzelli V. Pediatric Old World cutaneous leishmaniasis treated with oral fluconazole: A case series. Pediatr Dermatol 2018; 35:384-387. [PMID: 29582455 DOI: 10.1111/pde.13493] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cutaneous leishmaniasis has an incidence of 0.7-1.2 million cases per year and represents a growing concern in the outpatient dermatologic practice in Europe because of imported cases due to increased travel to risk areas and to immigration phenomena. When dealing with children, the treatment can be challenging because of side effects and pain of classic antimonial therapy leading to poor rates of course completion and requirement of sedation for several children. METHODS We retrospectively studied three cases of cutaneous leishmaniasis in pediatric patients, between the ages of 3 and 6 years of age, treated with oral fluconazole. We examined the efficacy, the tolerability, the safety profile and the cosmetic result of fluconazole at a dose of 6 mg/kg/daily for 6 weeks. RESULTS The patients had a complete resolution of their lesions with minimal scarring. No adverse effect was reported. The leishmaniasis species identified were L. major or L. tropica. CONCLUSION Considering sides effects and the parents' and the clinician's concern for systemic treatment in the pediatric population, fluconazole represents a valid, safe and easily manageable option for Old World cutaneous leishmaniasis in pediatric outpatients caused by L. major or L. tropica.
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Affiliation(s)
- Andrea Michelerio
- Department of Clinical-Surgical, Diagnostic and Pediatric Science, Institute of Dermatology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Stefania Barruscotti
- Department of Clinical-Surgical, Diagnostic and Pediatric Science, Institute of Dermatology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Grazia Bossi
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Valeria Brazzelli
- Department of Clinical-Surgical, Diagnostic and Pediatric Science, Institute of Dermatology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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Leishmania tropica isolates from non-healed and healed patients in Iran: A molecular typing and phylogenetic analysis. Microb Pathog 2018; 116:124-129. [DOI: 10.1016/j.micpath.2018.01.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 01/04/2018] [Accepted: 01/12/2018] [Indexed: 11/23/2022]
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Kulkarni MM, Reddy N, Gude T, McGwire BS. Voriconazole suppresses the growth of Leishmania species in vitro. Parasitol Res 2013; 112:2095-9. [PMID: 23392902 DOI: 10.1007/s00436-013-3274-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 01/06/2013] [Indexed: 11/29/2022]
Abstract
The digenetic protozoan Leishmania is dependent on ergosterol synthesis for growth and viability. We compared the in vitro activity of ergosterol synthesis inhibitor voriconazole with fluconazole and ketoconazole against cutaneous and visceral Leishmania species. We found the IC50 of voriconazole was comparable to ketoconazole and both were superior to fluconazole. Both ketoconazole and voriconazole were active against insect and mammalian stage parasites. This is the first report of the in vitro activity of voriconazole against leishmanial species.
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Affiliation(s)
- Manjusha M Kulkarni
- Division of Infectious Diseases and Center for Microbial Interface Biology, The Ohio State University, Columbus, OH 43210, USA
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El-Beshbishy HA, Al-Ali KH, El-Badry AA. Molecular characterization of cutaneous leishmaniasis in Al-Madinah Al-Munawarah province, western Saudi Arabia. Int J Infect Dis 2012; 17:e334-8. [PMID: 23253909 DOI: 10.1016/j.ijid.2012.11.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 11/11/2012] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Leishmaniasis is a parasitic disease affecting a large number of people worldwide. In this study we carried out the molecular characterization of cutaneous leishmaniasis (CL) in Al-Madinah Al-Munawarah Province, Saudi Arabia, confirming Leishmania major and Leishmania tropica as the prevalent species using molecular techniques. METHODS One hundred and five patients with suspected CL were identified from four different localities in Al-Madinah Al-Munawarah Province and Al-Miqat Hospital, Al-Madinah, Saudi Arabia. Thirty-four of the 105 patients were selected at random for molecular investigation. RESULTS Characterization of CL species by internal transcribed spacer 1 (ITS1) PCR-restriction fragment length polymorphism (RFLP) and kinetoplast DNA (kDNA) PCR established L. major and L. tropica as the causative organisms. kDNA PCR had a sensitivity of 90.7%, whereas ITS1 PCR had a sensitivity of 70.1%, thus facilitating the diagnosis and species identification. Parasite culture alone detected 39.2% and smear alone 55.3% of the positive samples. With the exception of kDNA PCR, all other assays were 100% specific. CONCLUSIONS This study provides the first findings for the comprehensive molecular characterization of CL in Saudi Arabia.
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Affiliation(s)
- Hesham A El-Beshbishy
- Medical Laboratories Technology Department, Faculty of Applied Medical Sciences, Taibah University, Al-Madinah Al-Munawarah, PO Box 30001, Saudi Arabia.
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Salerno C, Carlucci AM, Bregni C. Study of in vitro drug release and percutaneous absorption of fluconazole from topical dosage forms. AAPS PharmSciTech 2010; 11:986-93. [PMID: 20521179 DOI: 10.1208/s12249-010-9457-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 05/13/2010] [Indexed: 11/30/2022] Open
Abstract
The present study aimed to evaluate different dosage forms, emulsions, emulgels, lipogels, and thickened microemulsion-based hydrogel, as fluconazole topical delivery systems with the purpose of determining a formulation with the capacity to deliver the whole active compound and maintain it within the skin so as to be considered a useful formulation either for topical mycosis treatment or as adjuvant in a combined therapy for Cutaneous Leishmaniasis. Propylene glycol and diethyleneglycol monoethyl ether were used for each dosage form as solvent for the drug and also as penetration enhancers. In vitro drug release after application of a clinically relevant dose of each formulation was evaluated and then microemulsions and lipogels were selected for the in vitro penetration and permeation study. Membranes of mixed cellulose esters and full-thickness pig ear skin were used for the in vitro studies. Candida albicans was used to test antifungal activity. A microemulsion containing diethyleneglycol monoethyl ether was found to be the optimum formulation as it was able to deliver the whole contained dose and enhance its skin penetration. Also this microemulsion showed the best performance in the antifungal activity test compared with the one containing propylene glycol. These results are according to previous reports of the advantages of microemulsions for topical administration and they are very promising for further clinical evaluation.
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Mussi SV, Fernandes AP, Ferreira LAM. Comparative study of the efficacy of formulations containing fluconazole or paromomycin for topical treatment of infections by Leishmania (Leishmania) major and Leishmania (Leishmania) amazonensis. Parasitol Res 2007; 100:1221-6. [PMID: 17206508 DOI: 10.1007/s00436-006-0394-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Accepted: 11/14/2006] [Indexed: 11/28/2022]
Abstract
The development of alternative therapeutic approaches for cutaneous leishmaniasis (CL) has received considerable attention in recent research, including the identification of formulations for topical treatment. In the present study, the activity of two formulations was evaluated in BALB/c mice experimentally infected with either Leishmania (Leishmania) major or L. (L.) amazonensis, a hydrophilic gel containing 10% paromomycin (PAHG) and a cream containing 1% fluconazole (FLUC). After development of ulcerated lesions, infected mice were divided into three groups of five animals each: (1) PA group: Lesions were covered with 50 microl of PAHG; (2) FLUC group: Lesions were covered with 50 microl of FLUC, and (3) placebo group: treated with gel without paromomycin. During and after treatment, the size of lesions was determined weekly using a caliper. The efficacy of PAHG was significantly higher than that observed for FLUC for both Leishmania species. The PAHG formulation was effective in promoting the healing of ulcers in all animals 28 days after the beginning of treatment, whereas none of the animals was cured by FLUC. These results suggest that the PAHG formulation could be suitable for clinical studies and may represent an alternative formulation for the topical treatment of CL.
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Affiliation(s)
- Samuel Vidal Mussi
- Department of Pharmaceuticals, Faculty of Pharmacy, Federal University of Minas Gerais (UFMG), Av. Antônio Carlos, 6627, CEP 31270-901, Belo Horizonte, Minas Gerais, Brazil
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