Cutaneous leishmaniasis: “It starts with a pimple…”

Leishmaniasis is a parasitic tropical infectious disease caused by the bite of a sandfly. There are several forms of leishmaniasis: visceral, muco-cutaneous, disseminated and cutaneous leishmaniasis. Visceral leishmaniasis is also known as kala azar – a disease which can be fatal. The other forms of leishmaniasis affect the mucous membranes and/or skin and are not fatal.

Cutaneous leishmaniasis is the most common form and is endemic in Pakistan. It generally starts with a pimple or nodule that grows slowly into an ulcer. It is not life-threatening, but can cause serious and disfiguring lesions on the body.

Cutaneous leishmaniasis is caused by two different parasites: Leishmania major and Leishmania tropica. L. major is endemic in Pakistan’s southeastern provinces, Sindh and Punjab, as well as rural areas of Balochistan and Khyber Pakhtunkhwa, and self-heals within eight months. L. tropica is endemic in urban areas in Balochistan and Khyber Pakhtunkhwa province; it is more difficult to cure and tends to become chronic.

Cutaneous leishmaniasis is spread by the bite of the sandfly – an insect smaller than a normal mosquito. Sandflies carry a parasite that they inject into the skin when they bite people. The parasite goes into the cells and spreads, controlling the cells and causing damage to the skin. The human immune system may eventually destroy the parasite itself, but often it leaves a big lesion. Even after treatment, the lesion leaves a depressed scar.

The first-line treatment for cutaneous leishmaniasis is a drug called meglumine antimoniate. It is not produced locally in Pakistan, which means that the drugs have to be imported.

Across Pakistan, there is insufficient availability of meglumine antimoniate, which is not available in most of public hospitals. As a result, diagnosed patients are often forced to turn to the black market to procure their own medication. The quality of drugs bought on the black market is not assured, making treatment possibly dangerous, or at least inefficient, for the patient. They can also be prohibitively expensive for patients, costing as much as 1,000 rupees ($7.5) for a 5 ml vial. An adult patient might need 20 ml of the drug every day and the treatment can last two to three weeks. This means that even if a patient is able to source the drug, they would have to spend 60-80,000 rupees ($500 to $600) on treatment, which is unaffordable for many.

There is very low awareness of the disease, even amongst doctors, as it needs a specialist to diagnose it. People in Balochistan and Khyber Pakhtunkhwa call it ‘saal dana’ or ‘kaal dana’ – meaning a yearlong blister. Because it gives you disfiguring lesions, those with cutaneous leishmaniasis are often stigmatised. People often assume it is a sort of cancer, a deadly disease or a contagious infection passed on through touch. Young female patients and their families often fear that no one will marry them if they have a disfigured face. It all brings an immense amount of psychological trauma to the patient.

The only way to prevent cutaneous leishmaniasis is to protect yourself from getting bitten by sandflies. These insects live and breed in semi-humid and dry environments. They are so small that you can’t see them and, unlike a mosquito, they make no sound while flying. They are so small that they can get through the holes of a normal mosquito net. To protect themselves, people need to sleep under mosquito nets which have been soaked in an insecticide. Sandflies typically bite in the early hours of the morning and around sunset. They are unable to fly much more than a metre above ground, so if you sleep on a raised bed, you are already better protected.

Awareness raising is key: there need to be more public health campaigns about the disease – about how to prevent it, how to detect it, and on the importance of early diagnosis and treatment. The sooner it is diagnosed and treated, the less damage to the skin it causes, and the less the treatment costs. Treatment must be available, affordable and adapted to people’s needs. There is also a need for research into alternative and more effective models of treatment.

MSF's medical response in Pakistan is providing cutaneous leishmaniasis patients with specialist treatment and ensuring a steady supply of safe and effective medication. MSF also offers mental health support and carries out health promotion activities around how to prevent and treat the disease. MSF has cutaneous leishmaniasis programmes in Quetta and Kuchlak in Balochistan province, and Peshawar in Khyber Pakhtunkhwa province. In 2017, MSF treated close to 4,000 patients for the disease; in 2018, this figure is expected to exceed 5,000.