Background: In areas where it is not endemic, cutaneous leishmaniasis is often overlooked and signed out as nonspecific granulomatous dermatitis. Objectives: To demonstrate the spectrum of changes induced by leishmania in the skin with specific attention on unusual features. Patients/Methods: 36 biopsies from 30 patients were studied for patterns and composition of infiltrates as well as incidental findings. When intracytoplasmatic inclusions were few (21 cases), the diagnosis was confirmed by polymerase chain reaction specific for leishmania on paraffin-embedded tissue. Results: The pattern formed by infiltrates was predominantly nodular and often involved the subcutis. Granulomas were tuberculoid (23), sarcoidal (6), interstitial (4), or palisaded with fibrin in the center (3). Multinucleated giant cells were a common finding (21). Plasma cells were present consistently whereas eosinophils were lacking. Epidermal changes were: atrophy (20), acanthosis (16), pustulation (8), spongiosis (7), erosion (7), and ulceration (6). Features of vasculitis could be identified in 6 specimens. Keloidal collagen was seen in 10 specimens and elasophagocytosis in 14. Conclusions: Epidermal changes indicate rather acute lesions of cutaneous leishmanisis. Chronic lesions were usually devoid of epidermal changes, more often of the sarcoidal granulomatous type and had few intracytplasmatic inclusions. Unusual features in cutaneous leishmaniasis are elastophagocytosis, keloidal collagen and signs of vasculitis. Plasma cells and multinucleated giant cells in a granulomatous dermatitis are clues to cutaneous leishmaniasis and should alert a dermatopathologist to order PCR investigations to identify leishmania, if intracytoplasmatic inclusions are absent.