More than half of the patients with CL (54.0%) came to consultation with history of having handled their lesions; most of them with multiple products, usually chemicals (92%). However, literature shows higher frequencies of manipulation (71.2%) in populations from long-standing leishmaniasis endemic areas ⁽³⁾ and in studies from Latin American countries ^(10-12). In rural populations located in CL-endemic areas it is common to use traditional medicine, even in communities with health services ⁽³⁾. The origin of this cultural habit is attributed to the lack of information or distorted perceptions about the disease, the desire to prevent its progression, or the lack of an adequate diagnosis ^(10,12).

    Most patients in the study were male, probably because they have a higher risk of transmission ^(13,14). Similar findings have been reported in Guatemala and Ecuador ^(10,12), where infection is associated with occupational risks (agriculture, livestock). However, there are areas where children under 15 are the most vulnerable, especially when transmission occurs within the household ⁽¹³⁾.

    Lesion manipulation often occurs before seeking health care ^(3,12), which affects diagnosis negatively. Not only does it decrease the probability of detecting the parasite with the smear test, but it alters the morphology of the lesions, making clinical diagnosis by health personnel with limited training difficult. Based on the experience of the Cayetano Heredia Hospital, it is relatively common for any chronic ulcer in patients from rural areas to be classified as leishmaniasis, corresponding in many cases to other diseases such as sporotrichosis, pyogenic infections, insect bites, skin cancer, and skin tuberculosis, among others. Likewise, the handling of lesions delays and makes the diagnosis of CL more expensive. The usual procedure at the Cayetano Heredia Hospital is to obtain the result of the smear test within a few hours for non-manipulated lesions and to begin treatment the following day. However, in patients with manipulated lesions, the diagnosis exceeds one week and additional tests are required, such as cultures, pathological anatomy or polymerase chain reaction (PCR). This implies increased costs for patients (prolonging their stay in Lima) and for the health system.

    The time of illness is known to affect parasitological diagnosis, especially the classic diagnostic methods ^(15,16). In this study, it was found that the lesions with the longest time of illness (three months or more), independently of the presence of manipulation, had a lower proportion of positive smears, due to reduction of the parasitic load as a result of the immune response ⁽¹⁵⁾.

    Inhabitants of endemic communities manipulate their lesions mainly with caustic products; most of them used chemicals (92%) and less than half (43%) used plants. At least a third of those who manipulated their lesions recognized that there was an increase in the size of the lesion or inflammation. Lesion manipulation frequently results in inflammation, superinfection, necrosis ⁽³⁾ and first- to third-degree burns ⁽¹²⁾. Damage magnitude depends on the product used; the use of sulfur or acids generates more damage, which causes extensive subcutaneous tissue infection. The plants used caused less adverse effects on the lesions. In Colombia, it was found that people initially used “strong” treatments (burns, caustics) followed by “soft” treatments (plants) to heal ⁽¹¹⁾.

    Patients who come to the Cayetano Heredia Hospital recognize that handling their lesions with these substances causes pain and burns, but they hope the injury will heal. In some cases, they succeed; but most fail, because the burn is not regulated and causes many damaged tissues (dermal and lymphatic) to remain with parasites that later help lesion growth. Thermotherapy has used this knowledge to produce a regulated second-degree burn at a temperature below 52 °C with a time limit of 30 seconds ⁽¹⁷⁾.

    As for study limitations, the time between the last manipulation and the first contact with the referral center was not considered, which generates a confusing bias due to the chronicity of the injury. In addition, there could be a bias from the interviewer to adequately obtain the information since the population initially tends to deny the manipulation, underestimating its prevalence. The Leishmania species was not typified, therefore it could not be assessed whether it constitutes a confounding variable. Future studies with a prospective design and access to molecular methods could evaluate the effect of manipulation of CL lesions on parasite load, PCR results and Leishmania species identification.

    In conclusion, manipulation of cutaneous leishmaniasis lesions could determine a negative effect in the smear result of ulcerative lesions and also distort their morphology, which makes the clinical diagnosis difficult. This would prevent timely and free treatment provided by the Ministry of Health, which requires parasitological demonstration. First-level healthcare usually lack the clinical experience found in referral hospitals. Therefore, the greatest impact would be felt at first-level health care, where the main diagnostic method is light microscopy. This is why it is necessary to implement educational programs in endemic areas to reduce leishmaniasis lesions manipulation.

REFERENCES

1. Ampuero J. Leishmaniasis. Módulos técnicos. Series documentos monográficos N8 [Internet]. Lima: Ministerio de Salud. Oficina General de Epidemiología. INS; 2000 [cited on February 2, 2019]. Available at: http://bvs.minsa.gob.pe/local/OGEI/795_MS-OGE106.pdf.