Cutaneous leishmaniasis: 2026 guidelines for diagnosis and treatment.

Cutaneous leishmaniasis is a protozoan disease transmitted by the bite of infected sandflies. Its management varies according to the different species and clinical settings. We propose herein a new algorithm for the treatment of cutaneous leishmaniasis (CL) in France, in line with specific epidemiological features and therapeutic options available in this country. Due to its ease of use, topical paromomycin should be broadly used, including for multiple lesions (up to ten) and for lesions > 4 cm. Its main contraindication is proximity to mucosal areas. Cryotherapy, particularly where associated with intralesional meglumine antimoniate, is an interesting option for localized lesions of Old World CL, without risk of mucosal involvement. Pentamidine (intravenous or intramuscular) is particularly useful in remote settings and/or multiple lesions in Leishmania guyanensis infections. Liposomal amphotericin B should be contemplated in case of failure with other treatments, L. infantum in immunosuppressed patients, mucosal or rapidly evolving lesions in South America. Miltefosine, despite its teratogenicity, should be contemplated when hospitalization is impossible.