CPD • Therapeutic vignette CED Clinical and Experimental Dermatology CPD Complete cure of a large complex cutaneous leishmaniasis with a nonethanolic lipid based-amphotericin B gel A. Gupta, 1 K. Sardana, 1 A. Ahuja 2 and R. Kishan Gautam 1 1 Department of Dermatology; and 2 Department of Pathology, PGIMER and Dr Ram Manohar Lohia Hospital, New Delhi, India doi: 10.1111/ced.13883 Several drugs are used for the treatment of cutaneous leishmaniasis (CL); however, therapeutic recommenda- tions need to be individualized because no treatment is universally applicable. Although topical treatment can be used in cases with localized CL, systemic treatment is recommended in patients with complex CL who have > 4 skin lesions or a single lesion 50 mm in diameter and lesions occurring on the face, fingers, toes, joints or genitalia. 1 Many patients cannot toler- ate the pain associated with intralesional therapy and there are potentially serious adverse events (AEs) asso- ciated with systemic therapy. We report a patient with complex CL manifesting as a large plaque on the face, which showed complete clinical and parasitological cure following treatment with a lipid-based ampho- tericin B (AmB) gel. We propose that this may be a safe, nonirritating, effective and self-administered treat- ment option for CL. A 62-year-old woman presented with a 6-month history of lesions on her face and arm. The patient had a history of diabetes mellitus type 2 and hyperten- sion for 1 and 3 years, respectively, which were con- trolled on treatment and she was not on any immunosuppressive medication. Physical examination revealed an asymptomatic, well-defined erythematous plaque, 100 9 150 mm in size, with central crusting, on the patient’s left cheek (Fig. 1a), and two smaller lesions on her right forearm. The patient had no history suggestive of kala azar, and rK39 ELISA gave negative results. Histopathological examination revealed a dense perivascular lymphoplasmacytic infiltrate with few granulomas and giant cells in the dermis with numer- ous extracellular and intracellular Leishmania donovani bodies in the histocytes (Fig. 2a,b). The patient was diagnosed as having CL based on the classic clinical and histopathological findings. She had previously been diagnosed with CL and treated with a 4-week course of oral ketoconazole 3 months before she presented to us without any improvement. Considering the size of the lesion and the cosmetically sensitive site of involvement, we initially considered therapy with oral miltefosine, but its cost was pro- hibitive. The patient refused treatment with systemic or intralesional sodium stibogluconate/AmB. Based on a few reports showing favourable response of a topical ethanolic lipid-based AmB formulation in CL, we initi- ated our patient on a topical nonethanolic lipid-based 0.1% AmB gel, which is available in India (Amfy TM gel; Intas Pharmaceuticals Ltd., Ahmadabad, India), as such a formulation is more easily prepared than an ethanolic preparation. To enable better penetration, 12% salicylic acid ointment was applied to the lesions 1 h prior to the application of the AmB gel, which was applied twice daily. There was a marked improve- ment in the lesions after 2 months (Fig. 1b), and complete clearance of the lesions and absence of L. donovani bodies on histopathology was seen after 6 months of therapy (Figs 1c and 2c,d). Treatment was then stopped and the patient is being monitored for any features suggestive of relapse. To date, there are no consensus guidelines for the optimal management of CL. Most patients with local- ized lesions are treated with intralesional injections of sodium stibogluconate, which can be painful. There is a need for alternative therapies with a more favour- able safety profile, especially given the increasing resistance to antimoniates. AmB is a potent antileish- manial drug, which, because of its potential nephro- toxicity, is commonly used only as a second-line systemic therapy for patients with disseminated Correspondence: Dr Aastha Gupta, Department of Dermatology, Dr Ram Manohar Lohia Hospital, Baba Kharak Singh Road, New Delhi 110001, India E-mail: aasthagupta11@gmail.com Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 29 September 2018 ª 2018 British Association of Dermatologists Clinical and Experimental Dermatology 1 CPD