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Leprosy Follow-up

  • Author: Darvin Scott Smith, MD, MSc, DTM&H; Chief Editor: Michael Stuart Bronze, MD  more...
 
Updated: May 09, 2016
 

Further Outpatient Care

The WHO recommends that the monthly doses of rifampin be administered under direct observation during the visit.

Monthly outpatient follow-up is recommended during treatment, although weekly visits may be necessary if the patient experiences a leprosy reaction.

Follow-up laboratory studies during treatment include the following:

  • Urinalyses
  • CBC count
  • Creatinine
  • Liver function tests

Yearly skin scrapings taken from the 3 or 4 most active lesions are recommended.

Response to treatment

Successful treatment can result in flattening and elimination of nodules, papules, and plaques, as well as improved nerve function. Bacillary load is rarely a convenient method of assessing response to treatment. Noncompliance or drug resistance should be suspected if intact organisms are present after several months of treatment.

Once treatment is completed, the patient should be monitored for the next 5-10 years to evaluate for signs of relapse. To date, the relapse rate following completion of multidrug therapy has been 1% for both types of leprosy. In such cases, new bacillus-positive lesions may develop and should be treated with a thorough US regimen that incorporates once-daily rifampin (see Treatment).

Patients who have been successfully treated occasionally develop reversal reactions and further neuropathy. If skin biopsy samples are bacillus-negative, these patients are deemed to have a reversal reaction (see Complications).

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Deterrence/Prevention

Information campaigns about leprosy in high-risk areas are essential so that patients and their families, who were historically shunned from their communities, are encouraged to come forward and receive treatment.

Early diagnosis and treatment with multidrug therapy is the most effective way of preventing disabilities from leprosy, as well as preventing further transmission of the disease.[7]

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Prognosis

Recovery from neurologic impairment is limited, but skin lesions generally clear within the first year of therapy. Discoloration and skin damage typically persist.

Physical therapy, reconstructive surgery, nerve and tendon transplants, and surgical release of contractures have all contributed to increasing the functional ability in patients with leprosy. A common residual deformity is insensitive feet, as seen in persons with diabetes.

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Patient Education

Regional ambulatory clinics: The National Hansen's Disease Programs (NHDP) provide outpatient services and medical care to patients with leprosy in the United States and Puerto Rico. With the goals of prevention and early detection, the program supports delivery of services in areas with considerable populations of patients with leprosy. For additional information about these free services, contact the NHDP directly at 1-800-642-2477. The NHDP Center in Baton Rouge, La, provides free histopathologic services to facilitate diagnosis. Eleven outpatient HD clinics are located at hospitals, universities, and public health departments in Arizona, California, Florida, Illinois, Massachusetts, New York, Puerto Rico, Texas, and Washington. These clinics provide the following services:

  • Skin biopsy diagnostic confirmation
  • Additional medical care
  • Hospitalization for treatment complications
  • Consultations
  • Materials for professional and patient education

Patients with leprosy should be advised about the importance of continuing long-term therapy until the course of antibiotics is completed. The WHO recommends that the monthly administration of rifampin be directly observed.

In patient with leprosy who have advanced nerve damage, self-care techniques are of utmost importance in maintaining function and preventing further disability. The use of visual input to regulate activity, self-inspection, hygiene, and proper footwear can help prevent ulcer formation and tissue damage.

The WHO recommends examination of all household contacts of patients with leprosy, with careful instructions to seek medical care if signs and symptoms of leprosy appear.

Pregnancy in patients with leprosy can result in hormonal changes that lead to suppression of cell-mediated immunity, which may exacerbate symptoms of leprosy. Furthermore, pregnant women with leprosy are at greater risk of developing reactions and relapses. Type 1 reactions are more likely during the first few months following childbirth, whereas type 2 reactions typically occur during the third trimester of pregnancy and during lactation.[12]

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Contributor Information and Disclosures
Author

Darvin Scott Smith, MD, MSc, DTM&H Adjunct Associate Clinical Professor, Department of Microbiology and Immunology, Stanford University School of Medicine; Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Redwood City Hospital

Darvin Scott Smith, MD, MSc, DTM&H is a member of the following medical societies: American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, International Society of Travel Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Emily Anderson Kelly Stanford University

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Charles V Sanders, MD Edgar Hull Professor and Chairman, Department of Internal Medicine, Professor of Microbiology, Immunology and Parasitology, Louisiana State University School of Medicine at New Orleans; Medical Director, Medicine Hospital Center, Charity Hospital and Medical Center of Louisiana at New Orleans; Consulting Staff, Ochsner Medical Center

Charles V Sanders, MD is a member of the following medical societies: American College of Physicians, Alliance for the Prudent Use of Antibiotics, The Foundation for AIDS Research, Southern Society for Clinical Investigation, Southwestern Association of Clinical Microbiology, Association of Professors of Medicine, Association for Professionals in Infection Control and Epidemiology, American Clinical and Climatological Association, Infectious Disease Society for Obstetrics and Gynecology, Orleans Parish Medical Society, Southeastern Clinical Club, American Association for the Advancement of Science, Alpha Omega Alpha, American Association of University Professors, American Association for Physician Leadership, American Federation for Medical Research, American Geriatrics Society, American Lung Association, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Association of American Medical Colleges, Association of American Physicians, Infectious Diseases Society of America, Louisiana State Medical Society, Royal Society of Medicine, Sigma Xi, Society of General Internal Medicine, Southern Medical Association

Disclosure: Received royalty from Baxter International for other.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, Oklahoma State Medical Association, Southern Society for Clinical Investigation, Association of Professors of Medicine, American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Additional Contributors

Fred A Lopez, MD Associate Professor and Vice Chair, Department of Medicine, Assistant Dean for Student Affairs, Louisiana State University School of Medicine

Fred A Lopez, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, Infectious Diseases Society of America, Louisiana State Medical Society

Disclosure: Nothing to disclose.

Shwetha Ravindranath Katta, MD JJM Medical College, Davangere, India

Disclosure: Nothing to disclose.

Acknowledgements

Tara Ramachandra, MD Stanford University School of Medicine

Disclosure: Nothing to disclose.

References
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  2. Scollard DM, Adams LB, Gillis TP, Krahenbuhl JL, Truman RW, Williams DL. The continuing challenges of leprosy. Clin Microbiol Rev. 2006 Apr. 19(2):338-81. [Medline]. [Full Text].

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  9. Ustianowski AP, Lockwood DN. Leprosy: current diagnostic and treatment approaches. Curr Opin Infect Dis. 2003 Oct. 16(5):421-7. [Medline].

  10. Anderson GA. The surgical management of deformities of the hand in leprosy. J Bone Joint Surg Br. 2006 Mar. 88(3):290-4. [Medline].

  11. The World Health Organization. Transmission of Leprosy. Leprosy Elimination. Available at http://www.who.int/lep/transmission/en/. Accessed: April 15, 2016.

  12. Walker SL, Lockwood DN. Leprosy. Clin Dermatol. 2007 Mar-Apr. 25(2):165-72. [Medline].

  13. Anderson H, Stryjewska B, Boyanton BL, et al. Hansen disease in the United States in the 21st century: a review of the literature. Arch Pathol Lab Med. 2007 Jun. 131(6):982-6. [Medline].

  14. Martinez AN, Talhari C, Moraes MO, Talhari S. PCR-based techniques for leprosy diagnosis: from the laboratory to the clinic. PLoS Negl Trop Dis. 2014 Apr. 8 (4):e2655. [Medline].

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  24. Moschella SL. An update on the diagnosis and treatment of leprosy. J Am Acad Dermatol. 2004 Sep. 51(3):417-26. [Medline].

  25. National Hansen's Disease (Leprosy) Program. U.S. Department of Health and Human Services. Available at http://www.hrsa.gov/hansensdisease/index.html. Accessed: July 21, 2014.

  26. Rao PS, Sugamaran DS, Richard J, et al. Multi-centre, double blind, randomized trial of three steroid regimens in the treatment of type-1 reactions in leprosy. Lepr Rev. 2006 Mar. 77(1):25-33. [Medline].

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Hands with Z-thumbs, clawing, contractures, and shortening of fingers due to repetitive injury and healing. Ho Chi Minh City, Vietnam. Courtesy of D. Scott Smith, MD.
Patient with facial nerve palsy and contractures of the hand. Daloa, Ivory Coast. Courtesy of D. Scott Smith, MD.
Chronic insensate patch due to leprosy infection. Ho Chi Minh City, Vietnam. Courtesy of D. Scott Smith, MD.
Characteristic clawed hand deformity caused by ulnar involvement in leprosy. Daloa, Ivory Coast. Courtesy of D. Scott Smith, MD.
Chronic nonhealing ulcer at the metatarsal head resulting from loss of sensation in the feet. Karigiri, Tamil Nadu, India. Courtesy of Tara Ramachandra.
Multiple flat hypopigmented lesions on shoulder and neck, suggestive of multibacillary leprosy. Note ulceration of hypothenar area of hand, indicative of ulnar neuropathy. Redwood City, California, United States. Courtesy of D. Scott Smith, MD.
Man with advanced deformities caused by unmanaged leprosy. Keratitis, loss of eyebrow, thickened skin, and typical hand impairments. Ho Chi Minh City, Vietnam. Courtesy of D. Scott Smith, MD.
Histopathology of leprosy: Large numbers of acid-fast bacilli (in clusters) in histiocytes and within nerves. Fite-Faraco stain 500 X. Courtesy of Tara Ramachandra and D. Scott Smith, MD.
Patient with multibacillary leprosy showing subsequent erythema nodosum leprosum reaction. Santa Clara, California. Courtesy of D. Scott Smith, MD.
Patient with erythema nodosum leprosum type 2 reaction several weeks after initiation of drug therapy. This photograph was taken after tendon release. Redwood City, California. Courtesy of D. Scott Smith, MD.
Increased pigmentation on the face due to clofazimine therapy. Courtesy of D. Scott Smith, MD.
WHO Multidrug Therapy Regimens. Courtesy of WHO, Leprosy Elimination, http://www.who.int/lep/mdt/en/, accessed April 15, 2016.
Leprosy prevalence rates, 2014. Courtesy of WHO, Leprosy: Global situation, http://www.who.int/lep/situation/en/, accessed April 28, 2016.
Table 1. Multidrug Therapy Plan Recommended by the WHO
Type of Leprosy Daily, Self-Administered Monthly Supervised Months of Treatment
Paucibacillary Dapsone 100 mg Rifampicin 600 mg 6
Single-lesion paucibacillary Rifampicin 600 mg,



Ofloxacin 400 mg,



Minocycline 100 mg



N/A Single dose
Multibacillary Dapsone 100 mg,



Clofazimine 50 mg



Rifampicin 600 mg,



Clofazimine 300 mg 



12
Pediatric Dapsone 2 mg/kg,



Clofazimine 1 mg/kg



Rifampicin 10 mg/kg,



Clofazimine 6 mg/kg



Same as in adults
Table 2. US Recommendations for Multidrug Therapy [15]
Type of Leprosy Daily, Self-Administered Monthly Supervised Months of Treatment
Paucibacillary Dapsone 100 mg,



Rifampicin 600 mg



N/A 12
Single-lesion paucibacillary Dapsone 100 mg,



Rifampicin 600 mg



N/A 12
Multibacillary Dapsone 100 mg,



Rifampicin 600 mg,



Clofazimine 50 mg



N/A 24
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