eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections

Leprosy: Follow-up

Author: D Scott Smith, MD, MSc, DTM&H, Adjunct Assistant Professor, Department of Microbiology and Immunology, Stanford University; Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Redwood City Hospital
Coauthor(s): Tara Ramachandra, Stanford University School of Medicine
Contributor Information and Disclosures

Updated: Aug 19, 2008

Follow-up

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).

Complications

Careful attention to the development of reversal reactions during treatment and prompt and proper management will minimize long-term neurologic sequelae.

• Type 1 reaction
• Reversal reaction, or lepra type 1 reaction, is a delayed-type hypersensitivity reaction that arises when borderline leprosy shifts toward borderline lepromatous leprosy with treatment. These types of reactions reflect the development of an appropriate immune response and the local generation of tumor necrosis factor-alpha and interferon-gamma. The reaction is characterized by edema and erythema of existing skin lesions, formation of new skin lesions, neuritis, and additional sensory and motor loss.
• The likelihood of a type 1 reaction in patients with borderline leprosy is 30%.⁶
• Treatment includes nonsteroidal anti-inflammatory drugs (NSAIDs) and high-dose steroids. Prednisone is given at a dose of 40-60 mg/day with a decreasing taper of 5 mg every 2-4 weeks after improvement is demonstrated.
• Type 2 reaction
• Erythema nodosum leprosum (ENL), also known as lepra type 2 reaction, is a complication of lepromatous leprosy. It is characterized by the development of inflamed subcutaneous nodules accompanied at times by fever, lymphadenopathy, and arthralgias. High levels of tumor necrosis factor-alpha and immune complex deposition are associated with ENL.⁶ Treatment includes prednisolone, clofazimine, or thalidomide (see Images 9-10).
• Mild ENL reactions are treated with aspirin 600-1200 mg/day in 4-6 doses per day.
• Severe ENL reactions are treated with prednisone 60-80 mg/day with a slow taper, reducing by 5-10 mg every 2-4 weeks, depending on response and severity, to prevent residual deformity and nerve damage.
• Alternatively, thalidomide 100 mg PO 4 times per day (if available and in the absence of contraindications) can be used in cases that involve large subcutaneous plaques, arthritis, and temperature that exceeds 38.8°C.
• Lucio phenomenon is a severe complication of multibacillary leprosy that is marked by blue hemorrhagic plaques and necrotic ulcerations. The bacilli may extend to the endothelial cells along with the appearance of necrotic epidermis and vasculitis with thrombus formation and endothelial proliferation.

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.

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.⁶

Miscellaneous

Special Concerns

Leprosy eradication is a major goal of several health initiatives and a campaign through the WHO. Great strides have been made in defining the disease and treating it with multidrug therapy. Beyond treatment of the infectious phase of leprosy, management of drug reactions and many of the complications, including neuropathy, physical deformity, and psychologic responses, is essential and remains a challenge in resource-poor settings. Despite these challenges, the disease burden has been decreased, with a prevalence of 286,000 leprosy cases in 2005 compared to 804,000 cases in 1998.

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