Abstract
Cutaneous leishmaniasis (CL) is a neglected tropical disease with significant dermatological and psychosocial consequences, particularly in children. Despite its high prevalence in endemic regions like North Waziristan, Pakistan, limited research has examined the impact of lesion characteristics on pediatric quality of life (QoL). To determine the impact of lesion characteristics on dermatological QoL in children with CL in North Waziristan, Pakistan. A cross-sectional study was conducted from February 2023 to January 2024, including 384 children diagnosed with CL. QoL was assessed using the Children’s Dermatology Life Quality Index (CDLQI). Lesion characteristics like ulceration, activity status (active vs scarred), location, and treatment history were recorded. Logistic regression was used to identify predictors of poor QoL. Out of total of 384 children with cutaneous leishmaniasis, the mean age of participants was 9.96 ± 3.20 years, with a mean CDLQI score of 8.21 ± 4.71. Most lesions were dry (98.7%) and non-ulcerative (91.4%), commonly located on the head, neck, and face (64.6%). Non-ulcerative lesions were significantly associated with higher odds of QoL impairment (AOR = 9.97, 95% CI: 2.48-74.15, P = .006). Scarred lesions had lower odds of impairment compared to active ones (AOR = 0.05, 95% CI: 0.01-0.17, P < .001). Leg lesions were linked to higher QoL impairment (AOR = 2.74, 95% CI: 1.26-6.17, P = .012), whereas head/neck/face lesions were not (AOR = 0.69, 95% CI: 0.39-1.22, P = .193). Children who had received treatment reported worse QoL (AOR = 0.19, 95% CI: 0.06-0.47, P = .001). Lesion characteristics significantly influence QoL in children with CL. Non-ulcerative and active lesions, leg involvement, and prior treatment were associated with greater QoL impairment, whereas scarred lesions showed better outcomes.
Keywords
Highlights
● Cutaneous leishmaniasis significantly affects dermatological quality of life (QoL) in children, especially in endemic regions like North Waziristan, Pakistan.
● Non-ulcerative, active lesions and those located on the legs were strongly associated with poorer QoL outcomes.
● Scarred lesions showed a protective effect, while children who had received treatment reported worse QoL scores.
● Lesion type, location, and treatment history are critical predictors of QoL in pediatric cutaneous leishmaniasis cases.
Introduction
Neglected tropical diseases (NTDs) continue to pose a significant global health burden, disproportionately affecting impoverished populations in resource-limited settings. 1 Among these diseases, cutaneous leishmaniasis (CL) remains a major public health challenge, particularly in regions where access to healthcare, sanitation, and vector control measures is inadequate. 2 The World Health Organization (WHO) estimates that between 600 000 and 1 million new cases of CL occur annually, with 90% of cases concentrated in Afghanistan, Algeria, Brazil, Iran, Pakistan, Peru, Saudi Arabia, and Syria. 3
CL is caused by Leishmania parasites, transmitted by infected female sandflies. In Pakistan, Phlebotomus sergenti and Phlebotomus papatasi are key vectors, spreading Leishmania tropica and Leishmania major, respectively. 4 These species thrive in arid regions, contributing to CL endemicity in Khyber Pakhtunkhwa, Baluchistan, and the tribal districts, including North and South Waziristan.5,6 Despite high prevalence, the true burden of cutaneous leishmaniasis remains underestimated due to underreporting and limited diagnostic infrastructure, especially in remote and conflict-affected areas. Similar patterns have been observed in other conflict zones, such as northern Syria, where surveillance systems collapsed during the civil war, leading to a surge in cases in both endemic and previously hypoendemic regions. 3 Pakistan records 21 000 to 35 000 cases annually, though actual incidence is likely higher. 7 Environmental changes, poverty, and poor healthcare access sustain transmission, with children at heightened risk due to increased outdoor exposure. 6 The clinical manifestation of CL typically begins with the development of erythematous papules at the site of a sandfly bite, which may progress into ulcerative lesions. These lesions predominantly affect exposed areas such as the face, neck, arms, and legs, often resulting in permanent scarring which can be ulcerative or non-ulcerative. 8 Beyond its physical burden, CL is associated with significant psychosocial distress, stigmatization, and functional impairment and diminished health-related quality of life (HRQoL), particularly in children from endemic regions. 9 Social stigma, emotional distress, and impaired self-esteem are common among affected individuals, as visible scarring can lead to social exclusion and reduced marriage prospects in many cultural settings, further exacerbating the disease’s psychological impact.10,11
While previous research has extensively documented the epidemiology and clinical aspects of CL, its impact on children’s quality of life (QoL) remains underexplored. Studies suggest that children often present with more lesions on the face/head and experience greater social stigma compared to adults, 12 so evaluating QoL in children with CL, A brief conceptual framework is essential for understanding the broader consequences of the disease beyond its clinical presentation. The Children’s Dermatology Life Quality Index (CDLQI) provides a validated framework for assessing the impact of dermatological conditions on various aspects of daily life, including school performance, social interactions, and emotional well-being. 13
This study aims to address this research gap by systematically assessing the dermatological QoL in children diagnosed with CL in North Waziristan, a region particularly vulnerable due to population displacement and cross-border migration with Afghanistan. Specifically, we investigate the associations between lesion characteristics including type (ulcerative vs non-ulcerative), activity (active vs scarred), location, and treatment history and QoL outcomes. Additionally, we examine the association of demographic factors such as age, gender, and education level on QoL impairment and also to assess lesion characteristics that predict QoL impairment among children with CL. By providing a comprehensive understanding of how CL affects pediatric populations beyond its clinical manifestations, this study seeks to inform targeted interventions that improve both the physical and psychological well-being of affected children.
Materials and Methods
Study Design and Setting
This cross-sectional study was conducted from Feb 2023 till Jan 2024 in North Waziristan, Pakistan. Data were collected from 2 major public healthcare facilities: District Headquarter Hospital (DHQ) Miranshah and Civil Hospital (CH) Boya, which are key centers for CL treatment in the region.
Study Population and Sampling
The study included children aged 6 to 16 years with a confirmed diagnosis of cutaneous leishmaniasis (CL) based on microscopic examination of lesion samples. The age range was selected to capture both school-age children (6-12 years) and adolescents (13-16 years); however, we operationally define all participants as “children” in this study, as they experience distinct psychosocial impacts. Diagnosis of CL was confirmed through clinical evaluation, supplemented by laboratory confirmation. Skin scrapings or lesion aspirates were collected and examined using Giemsa-stained smear microscopy, specifically identifying the amastigote form of the pathogen, also known as Leishman-Donovan (LD) bodies.
Children with other chronic skin conditions or mental health disorders based on parental reporting and clinical assessment, were excluded to ensure the study focused solely on CL-related QoL impairment. The sample size was determined using OpenEpi, assuming a 50% prevalence of CL(as there was no prior study relevant to the area) and a 95% confidence level, resulting in a required sample size of 384 participants. A consecutive non-probability sampling technique was employed to recruit eligible children attending the hospitals during the study period. This study adheres to the STROBE guidelines for observational studies. 13
Data Collection
A structured clinical examination was conducted by trained healthcare professionals to confirm CL diagnosis and record lesion characteristics, including:
Lesion Type: Dry or wet
Appearance: Ulcerative or non-ulcerative
Activity: Active or scarred
Location: Head/neck/face, arm, leg
Disease Duration and Treatment History
Quality of Life Assessment
The Children’s Dermatology Life Quality Index (CDLQI), a validated tool, 14 was used to assess the impact of CL on QoL. The Pashto-translated version of the 10-item questionnaire was administered to ensure clarity and accuracy in responses. Each question was scored from 0 to 3, yielding a total score of 0 to 30, which was categorized as follows:
0 to 1: No effect on QoL
2 to 6: Small effect
7 to 12: Moderate effect
13 to 18: Very large effect
19 to 30: Extremely large effect
For analysis, CDLQI scores were dichotomized: “Significant effect” (moderate, very large, and extremely large impact or having cut off >7) versus “No effect” (small or no impact/ cut off <7).
Statistical Analysis
Data were analyzed using R/Rstudio. Descriptive statistics were computed for continuous variables (eg, age, QoL scores) as means and standard deviations (SD), while categorical variables (eg, lesion type) were summarized using frequencies and percentages. Demographic factors, including age, gender, and socioeconomic status, were incorporated as covariates in the analysis. Lesion characteristics were examined as potential predictors of quality of life, while confounders such as treatment status and lesion chronicity were adjusted for to ensure a comprehensive understanding of QoL determinants in children with CL. To assess the associations between lesion characteristics and QoL impairment, Chi-square tests were performed. Variables with significant P-values (≤.05) were included in a binary logistic regression model to control for confounders for the estimation of odds ratios, which quantify the strength of associations between lesion characteristics and QoL while adjusting for potential confounding variables. Univariate and multivariate logistic regression analyses were conducted, with results presented as both unadjusted and adjusted odds ratios (OR) along with their corresponding 95% confidence intervals (CI).
Ethical Considerations
The study was approved by the Advanced Studies and Research Board (ASRB) of Khyber Medical University Peshawar (No. KMU/IPHSS/Ethics/2022/AI/087) and the Ethical Committee Ethical Committee of Khyber Medical University (KMU). Informed consent was obtained from parents/guardians, and assent was secured from children aged ≥7 years. Confidentiality was maintained by anonymizing data prior to analysis. Participation was voluntary, and participants could withdraw at any stage without consequences
Results
A total of 384 children with cutaneous leishmaniasis were included in the study. The mean age of participants was 9.96 ± 3.20 years, and the mean Children’s Dermatology Life Quality Index (CDLQI) score was 8.21 ± 4.71. There was an equal proportion of genders, with 50% (192) being male and 50% (192) being female. The majority of participants had a primary-level education (n = 243, 63.28%), while smaller proportions had attained middle-level (n = 22, 5.73%) or matriculation-level (n = 12, 3.13%) education. Additionally, 27.86% (n = 107) had no formal education.
Lesion Characteristics
Most participants presented with dry lesions (n = 379, 98.70%), whereas only 1.30% (n = 5) had wet lesions as presented in Table 1. Non-ulcerative lesions were the predominant presentation (n = 351, 91.41%), with ulcerative lesions observed in 8.59% (n = 33). Active lesions were significantly more common (n = 352, 91.67%) compared to scarred lesions (n = 32, 8.33%). The head, neck, and face were the most frequently affected sites (n = 248, 64.58%), followed by the arm (n = 75, 19.53%) and the leg (n = 61, 15.89%). The majority of children had a history of treatment (n = 332, 86.46%), while 13.54% (n = 52) had not received treatment.
Descriptive Characteristics of Children with Cutaneous Leishmaniasis N:384.
Association Between Lesion Characteristics and Quality of Life
Table 2 presents the association between lesion characteristics and quality of life (QoL). The presence of non ulcerative lesions was significantly associated with a greater impact on QoL (86.1% vs 13.9%, P < .001). Similarly, active lesions were more likely to result in a significant QoL impact compared to scarred lesions (98.65% vs 1.35%, P < .001).Lesion location also associated with QoL outcomes. Children with lesions on the head, neck, and face were more likely to experience significant QoL impairment (74.44%) which followed by arm (18.83%) and then lastly at leg site 6.73%, P < .001). A history of prior treatment was paradoxically associated with a greater QoL impact. Among children reporting a no effect or small effect on QoL, 96.27% had received treatment, whereas only 3.73% of untreated children reported significant QoL impairment (P = .05).
Association of Quality of Life With Other Explanatory Variables.
Chi square/Fisher exact test.
Our study showed a notable association between lesion characteristics and CDLQI scores. As illustrated in Figure 1, children with ulcerative lesions consistently demonstrated higher CDLQI scores (indicating greater quality of life impairment) compared to those with non-ulcerative lesions across all age groups. The trend lines suggest that while quality of life impairment decreases with age in both groups, the disparity between ulcerative and non-ulcerative lesions persists throughout childhood and adolescence (ages 6-16).
Assocaition between age, CDLQI and Lesion appearance.
Logistic Regression Analysis
Table 3 presents the logistic regression model evaluating the impact of lesion characteristics on QoL. Children with non-ulcerative lesions had significantly higher odds of experiencing QoL impairment compared to those with ulcerative lesions (adjusted OR = 9.97, 95% CI: 2.48-74.15, P = .006). Children with scarred lesions had significantly lower odds of QoL impairment compared to those with active lesions (adjusted OR = 0.05, 95% CI: 0.01-0.17, P < .001). Lesions on the leg were significantly associated with greater odds of QoL impairment compared to those on the arm (adjusted OR = 2.74, 95% CI: 1.26-6.17, P = .012). In contrast, lesions on the head, neck, and face were not significantly associated with QoL impairment (adjusted OR = 0.69, 95% CI: 0.39-1.22, P = .193). Children who had not received treatment had significantly higher odds of QoL impairment compared to those who had received treatment (AOR = 0.19, 95% CI: 0.06-0.47, P = .001)
Logistic Regression Analysis of Factors Affecting Quality of Life.
Discussion
Our study showed the impact of CL on the dermatological quality of life (QoL) in children from North Waziristan, Pakistan. Our findings demonstrate that lesion characteristics, specifically, non-ulcerative and active lesions, as well as lesions on the face and legs are significantly associated with greater QoL impairment. Logistic regression analysis further supports these associations, highlighting that non-ulcerative lesions and leg lesions substantially increase the likelihood of significant QoL impairment.
A particularly concerning finding is that 27.86% of the children had never attended school. This has broader implications beyond dermatological health, reflecting structural barriers to education and healthcare access in the region. CL-related stigma and the visibility of lesions, particularly on exposed areas like the face, could contribute to school absenteeism. 15 Additionally, financial constraints, displacement, and limited healthcare infrastructure likely compound these challenges. 16 Addressing the QoL impact of CL should therefore be integrated into broader public health strategies that improve both educational and healthcare accessibility. Our study extends previous research, which primarily focused on the clinical and epidemiological aspects of CL, by underscoring its psychosocial burden in children. The strong association between non-ulcerative lesions and lower QoL may be counterintuitive at first, as ulcerative lesions are often perceived as more severe. 17 However, non-ulcerative lesions tend to persist for extended periods, resisting treatment and causing prolonged distress. These lesions may also be more conspicuous, increasing social stigma and psychological distress. 18 Furthermore, children with chronic non-ulcerative lesions may experience prolonged discomfort, itching, and irritation, further reducing their daily functioning and self-esteem. 19 The predominant species in North Waziristan is Leishmania tropica, which is known to cause dry, non-ulcerative lesions that are often chronic and treatment-resistant.2,20 This may explain the high proportion of non-ulcerative lesions in our sample and their association with significant QoL impairment. Species variation plays an important role in lesion presentation, treatment response, and prognosis, warranting further molecular studies in this region. 21
Leg lesions were significantly associated with lower QoL, likely due to their impact on mobility and physical activity. Although facial lesions are visibly prominent and may contribute to psychological distress, our findings did not demonstrate a statistically significant association with QoL impairment (P = .193). However, previous studies have highlighted the social stigma of visible lesions, which may still play a role in patient distress in certain cultural contexts. 16 These findings suggest that lesion location, rather than just clinical severity, plays a crucial role in determining QoL outcomes.
Our study found that children who had received treatment reported lower QoL than those who had never been treated. This finding may reflect disease severity, where those seeking treatment have more advanced or persistent cases. Additionally, certain CL treatments, such as intralesional injections, can be painful and cause side effects, which may temporarily worsen QoL. 22 Several other factors could explain this finding. One possibility is that children who seek treatment may have more severe disease, meaning their baseline QoL was already compromised before treatment initiation. 5 Additionally, some treatments for CL, such as intralesional injections or systemic therapies, are painful and may cause side effects, temporarily worsening QoL. 23 Moreover, prolonged or incomplete treatment courses may contribute to frustration, particularly if visible improvement is slow. 24 Another explanation is that untreated children might have milder or resolving cases, leading to less perceived impairment.
These patterns may also be influenced by the predominant Leishmania species in the region. The predominant species in Khyber Pakhtunkhwa, Pakistan is Leishmania tropica, 25 which is known to cause dry, non-ulcerative lesions that are often chronic and treatment-resistant. This may explain both the high proportion of non-ulcerative lesions in our sample and their association with significant QoL impairment. Species variation plays an important role in lesion presentation, treatment response, and prognosis, 26 warranting further molecular studies in this region. These findings emphasize the importance of timely and effective treatment, minimizing disease progression while ensuring that interventions do not inadvertently add to the patient’s burden.
Implications for Clinical Practice and Public Health
This study underscores the need for early detection and timely management of cutaneous leishmaniasis (CL) in children. Given the strong link between active lesions and impaired quality of life (QoL), clinicians should be trained to identify CL promptly and initiate treatment before complications arise. Public health officials should implement school- and community-based awareness programs to reduce stigma, particularly for children with visible lesions who may face psychological distress or social exclusion. In underserved areas like North Waziristan, strengthening local healthcare infrastructure and ensuring availability of diagnostics and treatment services are essential. Integrating psychosocial support within routine care could further improve outcomes for affected children.
Conclusion
Our findings highlight the substantial burden of cutaneous leishmaniasis on children’s dermatological quality of life. Non-ulcerative and active lesions were strongly associated with poorer QoL outcomes, emphasizing the need for early intervention. Lesions on the leg were significantly associated with greater QoL impairment compared to those on the arm, while lesions on the head, neck, and face were not significantly associated with QoL outcomes. Although descriptive analysis suggested a greater QoL impact among children with a history of treatment, logistic regression showed that untreated children had significantly higher odds of QoL impairment. This may reflect the severity and progression of untreated cases, underscoring the importance of early diagnosis and effective management. These findings highlight the need for timely treatment and psychosocial support to mitigate the disease’s impact on affected children.
Limitations and Future Research
This study’s cross-sectional design limits causal interpretation of the observed associations. Self-reported QoL data, despite using a validated tool, may be subject to bias. Additionally, findings from North Waziristan may not generalize to other CL-endemic regions. Future longitudinal studies should assess the evolving impact of lesion characteristics and treatment over time. Broader research is needed to explore the psychosocial dimensions of CL and evaluate the effectiveness of tailored interventions across diverse settings, ultimately guiding more patient-centered care strategies for children.
Supplemental Material
sj-docx-1-inq-10.1177_00469580251344057 – Supplemental material for Quality of Life in Pediatric Cutaneous Leishmaniasis: The Role of Lesion Type, Location, and Treatment
Supplemental material, sj-docx-1-inq-10.1177_00469580251344057 for Quality of Life in Pediatric Cutaneous Leishmaniasis: The Role of Lesion Type, Location, and Treatment by Farhad Ali Khattak, Naseem Khan Wazir, Hafsa Zia, Sajjad Khan, Ikram Khan, Muhammad Sohaib and Khalid Rehman in INQUIRY: The Journal of Health Care Organization, Provision, and Financing
Footnotes
Author’s Note
Farhad Ali Khattak is also affiliated with University of York, UK.
Ethical Considerations
This study was approved by the ethical board dated 23-12-2022 of Khyber Medical University Peshawar (No.KMU/IPHSS/Ethics/2022/AI/087).
Consent to Participate
Informed consent was obtained from all participants, and for children, consent was obtained from parents/guardians.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Office of Research, Innovation & Commercialization (ORIC), Khyber Medical University has supported the publication of this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data supporting this study are available upon reasonable request from the corresponding author.
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
