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Background  In the Kingdom of Saudi Arabia (KSA),  Leishmania major  and  L. tropica  are the main causative agents of Old World cutaneous leishmaniasis (CL). The national CL treatment regimen consists of topical 1% clotrimazole/2% fusidic acid cream followed by 1–2 courses of intralesional sodium stibogluconate (SSG); however, treatment efficacy is highly variable and the reasons for this are not well understood. In this study, we present a complete epidemiological map of CL and determined the efficacy of the standard CL treatment regime in several endemic regions of KSA.    Results  Overall, three quarters of patients in all CL-endemic areas studied responded satisfactorily to the current treatment regime, with the remaining requiring only an extra course of SSG. The majority of unresponsive cases were infected with  L. tropica . Furthermore, the development of secondary infections (SI) around or within the CL lesion significantly favoured the treatment response of  L. major  patients but had no effect on  L. tropica  cases.    Conclusions  The response of CL patients to a national treatment protocol appears to depend on several factors, including  Leishmania  parasite species, geographical location and occurrences of SI. Our findings suggest there is a need to implement alternative CL treatment protocols based on these parameters.    Electronic supplementary material  The online version of this article (10.1186/s13071-019-3453-4) contains supplementary material, which is available to authorized users.

parasites and vectors

Old World cutaneous leishmaniasis treatment response varies depending on parasite species, geographical location and development of secondary infection