Dermatologic Manifestations of Leprosy Treatment & Management

Updated: May 14, 2018
  • Author: Felisa S Lewis, MD; Chief Editor: Dirk M Elston, MD  more...
  • Print
Treatment

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) [92] 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. [93]

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 [94] :

  • Paucibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg once a month for 6 months; children aged 10-14 years – Dapsone at 50 mg/d plus rifampin at 450 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; children aged 10-14 years - Dapsone at 50 mg/d plus rifampin at 450 mg once a month plus clofazimine at 150 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; children aged 10-14 years - Single dose of rifampin at 300 mg, ofloxacin at 200 mg, and minocycline at 50 mg; treatment of single skin lesions not recommended for pregnant women and children younger than 5 years

Current US recommendations for the treatment of leprosy are as follows (regimens for children are general guidelines) [95] :

  • Paucibacillary disease - Dapsone at 100 mg/d plus rifampin at 600 mg/d for 1 year; for children, dapsone at 1 mg/kg/d plus rifampin 10-20 mg/kg/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; for children, dapsone at 1 mg/kg/d plus rifampin 10-20 mg/kg/d plus clofazimine at 1 mg/kg/d for 2 years (In the United States, clofazimine can only be obtained as an Investigational New Drug (IND) through the National Hansen's Disease Program [1-800-642-2477].)

Resistance to rifampin and dapsone has been reported. [96] WHO treatment recommendations are as follows [94] :

  • Rifampin resistance: 24-month treatment broken down as 6 months of 50-mg/d clofazimine, 400-mg/d ofloxacin, and 100-mg/d minocycline, followed by  18 mo of 50-mg/d clofazimine plus  400-mg/d ofloxacin or 100-mg/d minocycline

  • Dapsone resistance in paucibacillary disease - Clofazimine is substituted for dapsone; clofazimine at 300 mg once a month and 50 mg/d plus rifampin at 600 mg once a month for 6 months

  • Dapsone resistance in multibacillary disease: Treat as described above with only clofazimine and rifampin, omitting the dapsone

  • Other drugs that have been proposed as alternatives include moxifloxacin and rifapentine, but no specific regimens have been validated as effective.

Recommended monitoring guidelines for medications are found at the Hansen's Disease Recommended Treatment Regimens.

A modified course of MDT using rifampin and clofazimine was used effectively in patients with dapsone hypersensitivity syndrome. [97]

A small study also demonstrated the efficacy of a 4-week regimen of 600 mg of rifampin and 400 mg ofloxacin for paucibacillary disease. [98]

Treatment of pure neural leprosy often follows that of multibacillary disease.

Skin lesions usually resolve within the first year of treatment, although some may persist for up to 5 years in multibacillary disease.

Lack of improvement despite MDT may be due to anergy. This may be proven by a negative Mantoux test prior to administering the BCG injection. When given with MDT, BCG stimulates the suppressed cell-mediated immunity to produce a delayed hypersensitivity reaction, and induces clearance of bacilli. [99]

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. [100]

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).

Further inpatient care

Patients with leprosy may need hospitalization for acute complications. Sanatoria, which were widely used in the past, are no longer necessary. Most patients can be treated in an outpatient setting.

Community-based rehabilitation programs are important to integrate and support people with leprosy and their families. A current list of Hansen disease clinics in the United States can be obtained from the National Hansen's Disease (Leprosy) Program.

Next:

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.

Previous
Next:

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.

Previous
Next:

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.

Previous
Next:

Prevention

No skin or serologic tests are available to identify a carrier of leprosy.

In the southern United States, close contact with armadillos should be avoided. [4]

Household contacts of patients with lepromatous disease should be monitored annually for 5 years after diagnosis. There are no universal recommendations for chemoprophylaxis. Children especially should be observed for the development of disease. In endemic countries, chemoprophylaxis may be useful in controlling leprosy. The Prospective (sero-)Epidemiological Study on Contact Transmission and Chemoprophylaxis in Leprosy (COLEP) found that a single dose of rifampin was 57% effective in preventing leprosy in contacts for the first 2 years after diagnosis of a new index case. [101] A 6-year follow-up reported sustained lack of additional prevention beyond 2 years. However, this remained statistically significant. It also found that the most effective groups affected were in the contact groups of female index cases and in those who were in the contact groups of 2 or more leprosy patients. [102] In the United Kingdom, close contacts of lepromatous leprosy patients younger than 12 years are given rifampin at 15 mg/kg once a month for 6 months as prophylaxis. [103]

Attempts have been made to develop a vaccine against leprosy. Although not widely used, antileprosy vaccination can be immunoprophylactic and therapeutic. Current vaccines with various degrees of use are the BCG vaccine; the Mycobacterium w vaccine; the Mycobacterium avium-intracellulare complex (Mycobacterium ICRC) vaccine; and the BCG plus heat-killed Mycobacterium leprae, Mycobacterium tufu, and Mycobacterium habana vaccine.

The BCG vaccine has variable results in protecting certain populations; therefore, it is not widely prescribed. However, repeat immunization with the BCG vaccine may result in further protection. In the United Kingdom, the BCG vaccine is given to household contacts younger than 12 years.

In India, the Mycobacterium w and Mycobacterium ICRC vaccines are given. Mycobacterium w has a synergistic effect with chemotherapy, with accelerated clearing of the infection and shortening of treatment.

Previous
Next:

Long-Term Monitoring

Follow-up to monitor post-MDT reactions is no longer necessary because these reactions are rare. Nonetheless, prevention of disability and rehabilitation is important; therefore, suggested follow-up is 5-10 years after treatment is completed. Patients should be educated about the clinical signs of reoccurrence and should be instructed to return for an evaluation if they have any skin, eye, or nerve changes. Periodic assessments for neural impairment are recommended, and prompt treatment of reactions substantially reduces and prevents further damage and disability. Previous nerve involvement is predictive of further nerve function impairment.

Sensation and muscle strength in the hands, feet, and eyes should be checked on a regular basis. The eyes, nerves, and nose should be examined at follow-up to ensure timely recognition of reactivated disease.

Previous