eMedicine Specialties > Infectious Diseases > Skin and Soft-Tissue Infections
Leprosy: Treatment & Medication
Updated: Aug 19, 2008
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- Differential Diagnoses & Workup
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Treatment
Medical Care
In response to the increased incidence of dapsone resistance, the WHO introduced a multidrug regimen in 1981 that includes rifampicin, dapsone, and clofazimine. Some clinical studies have also shown that certain quinolones, minocycline, and azithromycin have activity against M leprae. The WHO recently recommended single-dose treatment with rifampin, minocycline, or ofloxacin in patients with paucibacillary leprosy who have a single skin lesion. However, the WHO still recommends the use of the long-term multidrug regimens whenever possible because they have been found to be more efficacious.
Multidrug Therapy Plan Recommended by the WHO
Open table in new window
Table
| Type of Leprosy | Daily, Self-Administered | Monthly Supervised | Months of Treatment |
|---|---|---|---|
| Paucibacillary | Dapsone 100 mg | Rifampicin 600 mg | 6-12 |
| Multibacillary | Dapsone 100 mg, Clofazimine 50 mg | Rifampicin 600 mg, Clofazimine 300 mg | 24 |
| Pediatric | Dapsone 2 mg/kg, Clofazimine 1 mg/kg | Rifampicin 10 mg/kg, Clofazimine 6 mg/kg | Same as in adults |
| Type of Leprosy | Daily, Self-Administered | Monthly Supervised | Months of Treatment |
|---|---|---|---|
| Paucibacillary | Dapsone 100 mg | Rifampicin 600 mg | 6-12 |
| Multibacillary | Dapsone 100 mg, Clofazimine 50 mg | Rifampicin 600 mg, Clofazimine 300 mg | 24 |
| Pediatric | Dapsone 2 mg/kg, Clofazimine 1 mg/kg | Rifampicin 10 mg/kg, Clofazimine 6 mg/kg | Same as in adults |
US regimens emphasize the use of rifampin, which is the most bactericidal drug used to treat leprosy. Although a single dose of 600 mg once monthly (the WHO standard) is considered bactericidal, treatment plans in the United States may include doses of 600 mg/day.
- Paucibacillary leprosy should be treated for 6-12 months with dapsone 100 mg/day unsupervised plus rifampin 600 mg/month supervised. This regimen should be followed by treatment with dapsone as monotherapy for 3 years in patients with tuberculoid leprosy or 5 years in patients with borderline lepromatous leprosy.
- Multibacillary leprosy should be treated for 24 months with dapsone 100 mg/day unsupervised, clofazimine 50 mg/day unsupervised, and rifampin 600 mg plus clofazimine 300 mg/month supervised.
- Corticosteroids have been used to treat nerve damage associated with leprosy, but a recent review of 3 randomized controlled trials shows no significant long-term effect.8 Prednisolone is believed to minimize pain and acute inflammation. The recommended initial dose is prednisolone 40 mg daily.
Surgical Care
- The goals of surgical treatment in patients with leprosy are to prevent further deterioration, to improve motor function, and, in some cases, to improve sensation.
- Preoperative requirements: First, a full sensory and motor appraisal with functional and occupational assessment must be completed to determine the extent of damage. Additionally, patients must have completed the multidrug therapy and should have negative skin smear results. The patient should not use steroids a few months before surgery, and acute neuritis should not be evident. Stiffness of hands and feet should be minimized with preoperative therapy.
- Neural surgery
- Attempts to restore autonomic function and sensation are rarely undertaken since little evidence shows that function is significantly regained. Draining of acute nerve abscesses and fascicular dissection can reduce the pressure on nerves and may improve sensation. In some cases, longitudinal epineurotomy may relieve some sensory loss. Considerable nerve function can be regained in the posterior tibial nerve with neurovascular decompression via release of the flexor retinaculum. Calcaneal bands can be slit to relieve distal compression of branches on the sole of the foot.
- Nerve grafts may be of some benefit in patients with localized lesions. Neural surgery may also be indicated in patients with unremitting nerve pain.
- Reconstruction and functional restoration5
- In leprosy management, the goal of most surgical procedures is to remedy motor paralysis due to primary nerve impairment. Claw fingers and Z-thumbs caused by ulnar nerve paralysis are among the most common deformities. Clawed hands are repaired with arthrodesis or with a tendon transfer to 1 of 4 insertion sites on the finger: interosseus tendons, proximal phalanx, dorsal extensor expansion, or flexor sheath annular pulleys. The palmaris longus, flexor digitorum superficialis, extensor carpi radialis longus, and extensor indices are tendons that can be used for transfer. Tendon transfers are also used to repair abduction and opposition of the thumb, dorsiflexion of the foot, and flexion and extension of the metacarpophalangeal and proximal interphalangeal joints, respectively.
- Contractures of the hand, such as the thumb web contracture, can be repaired with Z-plasty, and joint stability can be improved with tenodesis.
- The constrictions caused by repetitive injury and healing in patients with leprosy can be treated with several methods. Possible treatment options include removal of the carpal tunnel roof, ulnar nerve transposition anteriorly, and epicondylectomy.
- Procedures that limit hyperextension of the metacarpophalangeal joint or keep it in flexion are not indicated in the insensate hands of patients with leprosy, who suffer from continued weakness.
- Amputation is a last resort and is reserved for cases of extremely diseased tissue.
- Eye procedures: Loss of eyelid function may be treated with passing a strip from the temporalis muscle through the eyelid and connecting it to the inner canthus. Tarsorrhaphy may help narrow the opening of the eyelid, and canthoplasty reduces sagging of the eyelids.
- Cosmetic surgery: After the disease is controlled medically, the following cosmetic procedures may also be considered:
- Nasal reconstruction
- Removal of excess skin
- Replacement of eyebrows using transplants of scalp hair
- Removal of breast tissue formation due to gynecomastia
Consultations
Consultations may include an orthopedic surgeon, dermatologist, neurologist, and physical therapist, based on the needs of the individual patient.
Medication
The goals of pharmacotherapy are to eradicate the infection, to prevent complications, and to reduce morbidity.
The multidrug therapy plan recommended by the WHO can be used to plan therapy based on the type of leprosy (paucibacillary or multibacillary) and whether it is supervised monthly or self-administered daily (see Medical Care).
Antimycobacterial Agents
These agents have bactericidal and bacteriostatic activity against mycobacteria.
Dapsone (Avlosulfon)
Bactericidal and bacteriostatic against mycobacteria; mechanism of action is similar to that of sulfonamides, in which competitive antagonists of PABA prevent formation of folic acid, inhibiting bacterial growth. Part of a 2-drug regimen for treatment of paucibacillary leprosy; part of a 3-drug regimen for treatment of multibacillary leprosy.
Adult
Paucibacillary leprosy: 100 mg/d PO for 6-12 mo
Multibacillary leprosy: 100 mg/d PO for 24 mo
Pediatric
1-2 mg/kg/d PO; not to exceed 100 mg/d
May inhibit anti-inflammatory effects of clofazimine; hematologic reactions may increase with folic acid antagonists, eg, pyrimethamine (monitor for agranulocytosis during second and third mo of therapy); probenecid increases dapsone toxicity; trimethoprim with dapsone may increase toxicity of both drugs; because of increase in renal clearance, dapsone levels may significantly decrease when administered concurrently with rifampin
Documented hypersensitivity; known G-6-PD deficiency; porphyria; anemia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain weekly blood counts (first mo), then obtain WBC counts monthly (6 mo), then semiannually; discontinue upon significant reduction in platelets, leukocytes, or hematopoiesis
Caution in methemoglobin reductase deficiency, G-6-PD deficiency, or hemoglobin M because of the high risk of hemolysis and Heinz body formation; caution in patients exposed to other agents or conditions (eg, infection, diabetic ketosis) capable of producing hemolysis
Peripheral neuropathy can occur (rare)
Phototoxicity may occur when exposed to UV light
Rifampin (Rifadin, Rimactane)
For use in combination with at least 1 other antituberculous drug; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Most bactericidal drug used against M leprae. Cross-resistance may occur.
Treat for 6-9 mo or until 6 mo have elapsed from conversion to sputum-culture negativity.
Part of 2-drug regimen for treatment of paucibacillary leprosy; part of 3-drug regimen for treatment of multibacillary leprosy.
Adult
Paucibacillary leprosy: 600 mg/mo PO/IV for 6 mo
Multibacillary leprosy: 600 mg/mo PO/IV for 24 mo
Pediatric
10-20 mg/kg PO/IV; not to exceed 600 mg/d
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Documented hypersensitivity; reversal reactions or ENL; liver disease; jaundice; lactation
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC count and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur; may cause red-orange discoloration of urine, feces, saliva, sweat, sputum, and tears
Clofazimine (Lamprene)
Inhibits mycobacterial growth, binds preferentially to mycobacterial DNA. Has antimicrobial properties, but mechanism of action is unknown. Part of 3-drug regimen for treatment of multibacillary leprosy.
Adult
50 mg/d PO for 24 mo in combination with dapsone and rifampin
Pediatric
1 mg/kg/d PO qd in combination with dapsone and rifampin (when self-administered) and 6 mg/kg/d PO if supervised
Dapsone may inhibit anti-inflammatory activity of clofazimine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Patients should be warned that clofazimine may discolor skin, body fluids, and excrement; color ranges from pink to brownish-black; severe abdominal symptoms may require exploratory laparotomies; caution in patients with GI problems (eg, abdominal pain, diarrhea); skin discoloration due to drug may result in depression or suicide; apply oil to skin for dryness and ichthyosis
Minocycline
Used to treat leprosy in patients who cannot tolerate clofazimine.
Adult
100 mg/d PO
Pediatric
<8 years: Not recommended
>8 years: Not established
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupus-like syndromes may occur
More on Leprosy |
| Overview: Leprosy |
| Differential Diagnoses & Workup: Leprosy |
 Treatment & Medication: Leprosy |
| Follow-up: Leprosy |
| Multimedia: Leprosy |
| References |
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References
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Further Reading
Keywords
leprosy, Hansen's disease, Hansen disease, Mycobacterium leprae, M leprae, tuberculoid leprosy, TT leprosy, lepromatous leprosy, LL leprosy, BT leprosy, midborderline leprosy, BB leprosy, borderline lepromatous leprosy, BL leprosy, paucibacillary leprosy, PB leprosy, multibacillary leprosy, MB leprosy, indeterminate leprosy, borderline leprosy
