Further Outpatient Care
The WHO recommends that the monthly doses of rifampin be administered under direct observation during the visit. [23]
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:
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Urinalyses
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CBC count
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Creatinine
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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. The WHO defines relapse as marked increase in the bacillary index at any single site, usually accompanied by clinical deterioration. [24] To date, the relapse rate following completion of multidrug therapy has been around 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).
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. [25] However, vaccination with bacille Calmette-Guérin (BCG) is partially protective for leprosy. [26]
Prognosis
Without treatment, leprosy can lead to permanent muscle weakness, nerve damage, and disfiguration. Even with treatment, 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 or hands, 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, Georgia, Illinois, Massachusetts, New York, Puerto Rico, Texas, and Washington. These clinics provide the following services:
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Skin biopsy diagnostic confirmation
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Additional medical care
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Hospitalization for treatment complications
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Consultations
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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 patients 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. [19]
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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.
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Patient with facial nerve palsy and contractures of the hand. Daloa, Ivory Coast. Courtesy of D. Scott Smith, MD.
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Chronic insensate patch due to leprosy infection. Ho Chi Minh City, Vietnam. Courtesy of D. Scott Smith, MD.
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Characteristic clawed hand deformity caused by ulnar involvement in leprosy. Daloa, Ivory Coast. Courtesy of D. Scott Smith, MD.
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Chronic nonhealing ulcer at the metatarsal head resulting from loss of sensation in the feet. Karigiri, Tamil Nadu, India. Courtesy of Tara Ramachandra.
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Multiple flat hypopigmented lesions on shoulder and neck, suggestive of multibacillary leprosy. Note ulceration of hypothenar area of hand, indicative of sensory loss with curled 5th digit, from ulnar neuropathy. Redwood City, California, United States. Courtesy of D. Scott Smith, MD.
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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.
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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, MD, and D. Scott Smith, MD.
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Patient with multibacillary leprosy showing subsequent erythema nodosum leprosum reaction. Santa Clara, California. Courtesy of D. Scott Smith, MD.
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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.
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Increased pigmentation on the face due to clofazimine therapy. Courtesy of D. Scott Smith, MD.
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WHO map showing worldwide prevalence of leprosy in 2017. Courtesy of the WHO.
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2018 leprosy treatment guidelines. Courtesy of the WHO.
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Map of countries reporting rifampicin resistance in leprosy between 2009 and 2015. Courtesy of the WHO.
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2018 WHO guidelines for treatment of drug-resistant leprosy. Courtesy of the WHO.
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2018 guidelines for single-dose rifampicin. Courtesy of the WHO.
Tables
Age Group |
Drug |
Dosage and Frequency |
Duration |
|
Multibacillary Leprosy |
Paucibacillary Leprosy |
|||
Adult |
Rifampicin |
600 mg once a month |
12 months |
6 months |
Clofazimine |
300 mg once a month and 50 mg daily |
|||
Dapsone |
100 mg daily |
|||
Children (10-14 years) |
Rifampicin |
450 mg once a month |
12 months |
6 months |
Clofazimine |
150 mg once a month, 50 mg on alternate days |
|||
Dapsone |
50 mg daily |
|||
Children < 10 years or < 40 kg |
Rifampicin |
10 mg/kg once a month |
12 months |
6 months |
Clofazimine |
100 mg once a month, 50 mg twice weekly |
|||
Dapsone |
2 mg/kg daily |
|||
Resistance Type |
Treatment |
|
First 6 months (daily) |
Next 18 months (daily) |
|
Rifampicin resistance |
Ofloxacin 400 mg* plus Minocycline 100 mg plus Clofazimine 50 mg |
Ofloxacin 400 mg* or Minocycline 100 mg plus Clofazimine 50 mg |
Ofloxacin 400 mg* plus Clarithromycin 500 mg plus Clofazimine 50 mg |
Ofloxacin 400 mg* plus Clofazimine 50 mg |
|
Rifampicin and ofloxacin resistance |
Clarithromycin 500 mg plus Minocycline 100 mg plus Clofazimine 50 mg |
Clarithromycin 500 mg or Minocycline 100 mg plus Clofazimine 50 mg |
*Ofloxacin 400 mg can be replaced by levofloxacin 500 mg or moxifloxacin 400 mg |
||
