Daie Parizi 2015

Methods	Study design: randomised single blind parallel clinical trial Setting/location: Leishmaniasis Center in Dadbin Health Care Clinic in Kerman, Iran Study period: 15 months. Participants recruitment: 8 months (December 2012 to August 2013) Sample size calculation: based on the data from previous study, and by considering the confidence interval of 95%, sample size was determined as 23 lesions per group. Regarding to a possible loss in follow‐up period, finally 32 lesions were allocated in each group
Participants	Type of Leishmania: L amastigote (Leishman‐Donovan bodies) Inclusion criteria: positive direct smear or documented skin biopsy for L amastigote (Leishman‐Donovan bodies), > 2 years of age, no previous therapy for leishmaniasis, ulcerated lesions for those lesions that were included in Thio‐Ben + cryotherapy (TC) group Exclusion criteria: pregnancy, lesions on the eyelids and lips, having more than 5 lesions, positive history of confirmed immunodeficiency disorders or immunosuppression, disease duration for more than a year, positive history of allergy or hypersensitivity to thioxolone, benzoxonium chloride, or pentavalent antimony compounds. N randomised: 64 lesions of 47 participants, Thio‐Ben + cryotherapy (TC) group (32 lesions, 22 participants), ILMA (32 lesions, 25 participants) Withdrawals: 16 lesions of 9 participants (10 lesions from TC and 6 from ILMA group) were removed from the study arms because of their poor adherence to the trial protocol and lost to follow‐up. Additionally, one participant (with one lesion) was excluded because of developing a hypersensitive reaction to MA in the course of the treatment. Lesions assessed: 48 lesions in 47 participants. TC: 22, ILMA: 25 Mean age (SD): TC 23.5 years (16.4), ILMA 25.4 years (19.4) Sex (n (%)): TC: male 6 (27.2%), female: 16 (72.7%); ILMA: male 19 (76%), female: 6 (24%) Baseline data: Location of lesion: TC: face 5 (22.7%), elbow 1 (4.5%), hand 13 (59.1%), foot 1 (4.5%), ear 1 (4.5%), arm 1 (4.5%), neck 0. ILMA: face 6 (24%), elbow 3 (12%), hand 10 (40%), foot 2 (8%), ear 1 (4%), arm 2 (8%), neck 1 (4%) Mean (SD) duration of disease: TC, 4.1 months (2.9); ILMA, 3.1 months (2.4)
Interventions	Type of interventions: Group 1: 1–2 mL of tincture of Thio‐Ben (depending on the size of the lesion) topically by a cotton swab that was held with a mild pressure on the lesion for about 3–4 min, every other day Group 2: ILMA containing 8.1% Sb5+ (81 mg/mL), once a week with the dose of 0.5–2 mL per lesion Co‐intervention: in addition, at the beginning, and then every 2 weeks, cryotherapy with liquid nitrogen (−195°C) was performed for all lesions in both groups Duration of intervention: 3 months or until the lesion was cured, whichever came first Duration of follow‐up: 6 months after the termination of the treatment to evaluate the incidence of relapse (reported at 1 month, 2 months, 5 months)
Outcomes	Clinical cure of the lesions: Complete cure: complete subsidence of induration and re‐epithelialisation of the lesion Partial cure: reduction of the size of lesion by 50% and more Improvement: reduction of the size of lesion by less than 50% No response: no significant reduction of the size of lesion Deterioration: any increase in the size of the lesion Adverse effects Relapse: participants that developed with relapse of the lesions at the previously involved area Time points reported: clinical cure was reported when it occurs or for a maximum of 3 months. Adverse effects were assessed at follow‐up during therapy; they were the safety endpoints of the treatments, and 6 months after the termination of the treatment
Notes	Study funding sources: this study was supported and funded by the Vice Chancellor for Research, Kerman University of Medical Sciences. The founder had no financial or proprietary interest in any material or method used in this study and had no role in study design, data collection and analysis, or preparation of the manuscript. Possible conflicts of interest: no conflict of interest
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Randomised allocation was performed by blocked randomisation method with block size of 2
Allocation concealment (selection bias)	Low risk	Randomised allocation was performed by blocked randomisation method and was prepared by the analyst of the research team who had no clinical involvement in the trial.
Blinding of participants and personnel (performance bias) All outcomes	High risk	Blinding was impossible
Blinding of outcome assessment (detection bias) All outcomes	Low risk	Assessing the outcomes and data analyst were blinded to group assignment. The photographs were reviewed by the dermatologist of the research team who was blinded to study groups. The photographs did not contain any indicator that could help differentiate the group of the lesion.
Incomplete outcome data (attrition bias) All outcomes	High risk	The numbers of withdrawals were high in both groups: 31.25% (10/32) in TC group and 18.75 % (6/32) in the ILMA group. Participants were removed from the study arms because of their poor adherence to the trial protocol and lost to follow‐up. No intention‐to‐treat analysis was done.
Selective reporting (reporting bias)	Low risk	The study published reported our outcomes
Other bias	Low risk	Other items assessed correctly reported