Cutaneous leishmaniasis in Afghanistan

Old World cutaneous leishmaniasis (OWCL) is a sand fly-transmitted skin infection caused by Leishmania species that extends from West Africa to China. Afghanistan probably has the highest burden of OWCL and is home chiefly to Leishmania tropica and Leishmania major, which cause anthroponotic and zoonotic CL, respectively. Although data on the species distribution in Afghanistan are patchy, L. tropica predominates over L. major, reflecting its concentration in large cities. CL prevalence in Afghanistan increases with increasing age to peak at 5-10 y, depending on the local epidemiology. Clinically, there is a spectrum of lesions common to both main species with nodules, ulcerated nodules and papules accounting for the majority (50-80%) of lesions at presentation. When healed, CL lesions leave pale scars that often have deleterious psychosocial effects. Leishmania control involves vector control and treating patients, but these are severely challenged by decades of war and disruption to the health system. In the public sector, only injectable antimonials, sodium stibogluconate or meglumine antimoniate, are available and, anecdotally, efficacy remains high. Few clinical trials have been conducted in Afghanistan and data support antimonial efficacy; small clinical series suggest good efficacy of oral miltefosine against the two main species. Herein, we focus our review on the epidemiological and clinical aspects of CL in Afghanistan and suggest avenues of future research.