Dermatologic Manifestations of Leprosy Treatment & Management

  • Author: Felisa S Lewis, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Aug 5, 2011
 

Medical Care

The management of leprosy includes early pharmacotherapy and physical, social, and psychological rehabilitation. The goals of pharmacotherapy are to stop the infection, reduce morbidity, prevent complications, and eradicate the disease. Since 1981, multidrug therapy (MDT) has been advocated by the World Health Organization (WHO)[38] and the United States government. MDT prevents dapsone resistance, quickly reduces contagiousness, and reduces relapses, reactions, and disabilities. If a patient has been previously treated with dapsone monotherapy, re-treatment with a modified MDT regimen of rifampin, clofazimine, and dapsone can reduce or delay the risk of relapse.[39]

The length of treatment ranges from 6 months to 2 years. Patients are considered noninfectious within 1-2 weeks of treatment (usually after the first dose). These drugs are conveniently packaged in monthly calendar blister packs. Monitor for drug resistance and adverse reactions to medications.

  • Paucibacillary disease can be treated with a combination of 2 drugs, whereas multibacillary disease requires triple-drug therapy. Single skin lesions (paucibacillary) can be treated with a single dose of 3 drugs. The length of treatment depends on the type of disease and on the access to drugs.
  • WHO and US treatment regimens for paucibacillary and multibacillary disease are listed below. Therapy for single skin lesions is not universal, because 80% of single skin lesions heal spontaneously. Therefore, only the WHO has a recommended treatment.
  • Current WHO recommendations for treatment of leprosy are as follows:
    • Paucibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg once a month for 6 months
    • Multibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg once a month plus clofazimine at 300 mg once a month and 50 mg/d for 1 year
    • Single skin lesion - A single dose of rifampin at 600 mg, ofloxacin at 400 mg, and minocycline at 100 mg
  • Current US recommendations for the treatment of leprosy are as follows[40] :
    • Paucibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg/d for 1 year
    • Multibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg/d plus clofazimine at 50 mg/d for 2 years
  • In patients taking dapsone, the CBC count should be checked frequently early during the therapy and then less frequently later during therapy.
  • A modified course of MDT using rifampin and clofazimine was used effectively in patients with dapsone hypersensitivity syndrome.[41]
  • A small study also demonstrated the efficacy of a 4-week regimen of 600 mg of rifampin and 400 mg ofloxacin for paucibacillary disease.[42]
  • Skin lesions usually resolve within the first year of treatment, although some may persist for up to 5 years in multibacillary disease.
  • One promising avenue to measure treatment efficacy may be to follow immunoglobulin G levels of LID-1 fusion protein, and ML0405 and ML2331, both recombinant proteins. One study of Brazilian and Venezuelan patients demonstrated a decrease in reactivity across the clinical spectrum (highest levels in lepromatous leprosy → lowest levels in paucibacillary leprosy) and with MDT.[43]
  • Potential deformities can be prevented by educating patients about how to minimize existing nerve damage and by treating any sequelae of this damage. Close follow-up is important to ensure patient compliance (see Complications and Further Outpatient Care).
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Surgical Care

  • Emergency surgery may be necessary if a patient with profound nerve inflammation presents with a nerve abscess or loss of nerve function secondary to compression. Prompt recognition and surgical drainage of the abscess can often restore nerve function.
  • Elective surgery may be required for correction of lagophthalmos (ie, inability to close the eye).
  • Reconstructive surgery can be used to repair nasal collapse in patients with lepromatous leprosy, but it is not recommended until the disease has been inactive for a minimum of 1 year.
  • Other surgery may be needed to improve function or for cosmesis.
  • Contractures can be surgically repaired.
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Consultations

  • Consultations with an ophthalmologist, a plastic surgeon, an orthopedic surgeon, an otolaryngologist, a neurosurgeon, and/or a neurologist may be necessary.
  • Reasons for a consultation with an ophthalmologist include the following:
    • Lagophthalmos
    • Erythema nodosum leprosum (ENL)–induced iritis
    • Direct invasion of the anterior chamber of the eye by Mycobacterium leprae
    • Corneal and conjunctival insensitivity
    • Infection or scarring from involvement of CN V and CN VII
    • Cataracts
  • Specialists in rehabilitation medicine, including physical and occupational therapists, can help in reducing morbidity.
  • Consultation with a prosthetics specialist also may be appropriate.
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Activity

Restrictions on activity depend on the extent of nerve damage.

  • In patients with bone or joint destruction, weight bearing should be minimized.
  • Patients with anesthesia of the limbs must be educated about their condition, and they should wear appropriate protection (especially footwear).
  • Plantar ulceration requires rest and avoidance of weight bearing.
  • Weakness or paralysis requires physical therapy to prevent contractures.
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Contributor Information and Disclosures
Author

Felisa S Lewis, MD  Staff Physician, Department of Dermatology, Madigan Army Medical Center

Felisa S Lewis, MD, is a member of the following medical societies: American Academy of Dermatology, International Society of Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Theresa Dressler Conologue, DO, FAAD  Physician, Department of Dermatology, Geisinger Medical Center

Theresa Dressler Conologue, DO, FAAD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, and American Society for Laser Medicine and Surgery

Disclosure: Nothing to disclose.

Elyse Harrop, MD  Clinical Instructor, Department of Dermatology, Metrohealth Medical Center

Elyse Harrop, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Terry L Barrett, MD  Clinical Professor of Dermatology and Pathology, University of Texas Southwestern School of Medicine; Director, ProPath Dermatopathology, Dallas, Texas

Terry L Barrett, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, College of American Pathologists, and United States and Canadian Academy of Pathology

Disclosure: Nothing to disclose.

Michael J Wells, MD  Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD  Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Texas Medical Association

Disclosure: Nothing to disclose.

Catherine M Quirk, MD  Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania

Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

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