Twenty years after the first cases of echinococcal disease were treated with albendazole, it has become an important component in the overall management of both cystic and alveolar echinococcosis. This paper reviews some of the key steps and issues facing those who work in clinical research and who deal on a day-to-day basis with echinococcal disease. In many situations, chemotherapy alone is sufficient, but it is also used as an adjunct to surgery and to minimally invasive approaches to cyst management. While treatment may not be as effective as hoped, attempts to provide new regimens are progressing to increase cure rates further. There is now a greater understanding of the limitations of all approaches, and treatment guidelines as developed by the World Health Organization are now widely followed. As diagnostic tools are ever more widely available, the question as to who should be treated in endemic communities has to be answered.