[Leish-l] inquiry

Wed Jun 8 14:30:27 BRT 2011

Dear Tony,

Thank you so much for letting us know your invaluable experience with
detailed information on treating CL lesions by physical means. This is
certainly a much needed 'education' for me. I am not qualified to
comment on what you said, but wish to provide the following information:

1.	The device, ThermoSurgery instrument, delivers radiowave to
generate heat at 50 C (pretty precisely) for 30 seconds under anesthesia
with 2% lidocaine (John David's article TSRSTMH 100, 642. 2006). No
re-emergence of lesion after 1.5 years according to Abhay's e-mail
message.

2.	I was told that the Tropical Medicine Center of Cukurova
University, Adana discontinued cryotherapy for treating CL because
lesions re-merged. Intra-lesion antimony injection is currently in
practice.

KP

________________________________

From: Anthony Bryceson [mailto:a.bryceson at doctors.org.uk] 
Sent: Wednesday, June 08, 2011 6:30 AM
To: Chang, Kwang-Poo
Cc: John David; Satoskar, Abhay; vishwamohan_katoch at yahoo.co.in; Raj;
leish-l at lineu.icb.usp.br
Subject: Re: [Leish-l] inquiry

I have been following the correspondence on heat therapy with interest,
having explored it myself in the past.

There are two forms of heat therapy. The first uses heat physiologically
to promote natural healing, while the second uses heat as form of
cautery to burn out the lesion.

To promote natural healing, heat is applied to the skin at temperatures
in the range 37-40oC. Many species of cutaneous Leishmania do not
survive at 37oC and lymphocytes act most efficiently at 40oC. This form
of therapy disadvantages the parasite and advantages the host.
Temperatures must be accurately applied because the skin burns at
42-45oC, depending on the method and duration of application. The
difficulty of this approach is how to achieve accurate delivery and
maintain the temperature for many hours per day over many days.
Infra-red treatment, as introduced by George Rahim in Baghdad, probably
comes into this category; heat from a lamp was applied through a cone,
but temperature control was difficult and it was not easy to prevent
burns. At the Hospital for Tropical Diseases, London, we developed a
method whereby  a fine coiled wire was imbedded in a flexible pad made
from the stuff that dentists use for making plates. Pads could be custom
made, for example to fit the pinna of an ear. A thermistor was
incorporated alongside the heating wire in the pad with feedback to the
power box so as to maintain an accurate-ish temperature. Nevertheless it
was difficult absolutely to prevent burns and patients were effectively
tied to the machine for long periods of time. The method worked
reasonably well, but we abandoned it as impractical. Eduardo Missoni
wrote up some case histories; but we never published anything formally. 

 Missoni E. Heat treatment of cutaneous leishmaniasis. Trop Doct.
1984;14:46.

WRAIR developed a method whereby water from a water-bath was pumped
through an intravenous fluid bag that was applied over the lesion. But I
understand that the system did  not seem practiacble and was not taken
forward. 

Heat cautery burns out the lesions, and the Thermomed instrument that
delivers a temperature of 50oC between two electrodes implanted into the
lesion comes into this category. It must of course be used with local
anaesthetic. I have never used it; but its advantage seems to be that it
is painless, and effective, often at a single setting if the lesions is
small. John David speaks very highly of it. It is not suitable for all
lesions and there can be complications. see   

http://www.crd.york.ac.uk/CMS2Web/ShowRecord.asp?LinkFrom=OAI&ID=3201000
1498 

for example: "Post treatment wound care is essential, as blistering and
secondary infection are the most common adverse effects." With a power
box to carry around and electrodes to sterilise, i don't know how useful
it may be under field conditions.

Cryotherapy and simple curettage are other techniques that have been
used successfully to destroy leishmanial sores.

Curettage requires local anaesthetic, but is simple to perform.  The
curette can be cleaned and safely sterilised by flaming in small steel
dish with a few ml of methylated spirit (wait a moment before picking up
the curette). Currie published a small study, and was pleased with the
results.

 Currie MA. Treatment of cutaneous leishmaniasis by curettage. Br Med J
(Clin Res Ed). 1983;287:1105-1106.

If I were looking for a simple portable method of treatment in the field
I would seriously consider curettage under local anaesthetic. Perhaps
there is a dermato-leishmaniac out there who would like  to compare
curettage with intralesional SSG? But please plan the study carefully -
the literature on treatment of CL is littered with uninterpretable
publications. It's time we got our act together.

Anthony Bryceson

On 6 Jun 2011, at 17:02, Chang, Kwang-Poo wrote:

Any chance to make it available for additional trials elsewhere ?

I recall your statement in our conversation about the advantage of this
instrument over the heating lamp. That is to maintain the specific
elevated temperature uniformly throughout the skin lesion for a
sustained period. The 50 C must be the effective temperature that has
been experimentally determined. It seems to be a tolerable temperature
to human skin ?  Dr. Sharma may comment on this medically as a
dermatologist ?

KP

________________________________

From: John David [mailto:jdavid at hsph.harvard.edu] 
Sent: Sunday, June 05, 2011 11:18 PM
To: Chang, Kwang-Poo
Cc: Sharmanl; Satoskar, Abhay; Raj; Petr Volf; leish-l at lineu.icb.usp.br;
hgoto at usp.br; elfadil_abass at yahoo.com; vishwamohan_katoch at yahoo.co.in
Subject: Re: [Leish-l] inquiry

The Themomed instrument shown below can produce accurate 50 degrees C
plus or minus 0.2 degrees temperature by radio wave.

from Themorsurgery Technologies. Picture below.

Two papers of a trial in Brazil and one in Afghanistan on CL below.

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