Medication Summary

The goals of pharmacotherapy are to eliminate the infection, to prevent complications, to halt its further transmission and spread, and to reduce morbidity.

The multidrug therapy (MDT) 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).

Clofazimine is no longer commercially available in the United States. It is available only by obtaining an investigational new drug (IND) permit from the National Hansen’s Disease Program (NHDP) from the U.S. Department of Health and Human Services. For more information, visit www.hrsa.gov/hansensdisease/ or call 1-800-642-2477.

Class Summary

These agents have bactericidal and bacteriostatic activity against mycobacteria.

Dapsone

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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 3-drug regimen for treatment of both paucibacillary (6 months) and multibacillary (12 months) leprosy.

Rifampin (Rifadin)

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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 a 2-drug regimen for treatment of paucibacillary leprosy; part of a 3-drug regimen for treatment of both paucibacillary (6 months) and multibacillary (12 months) leprosy.

Clofazimine (Lamprene)

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Inhibits mycobacterial growth, binds preferentially to mycobacterial DNA. Has antimicrobial properties, but mechanism of action is unknown. Part of a 2-drug regimen for treatment of paucibacillary leprosy; part of a 3-drug regimen for treatment of both paucibacillary (6 months) and multibacillary (12 months) leprosy. No longer commercially available in the United States; available only by obtaining an investigational new drug (IND) permit from the National Hansen's Disease (Leprosy) Program (NHDP).

Minocycline (Minocin, Solodyn)

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Minocycline is a semisynthetic tetracycline. Has bacteriostatic activity. Inhibits protein synthesis, and is selectively concentrated in susceptible organisms. It is used in single-lesion paucibacillary leprosy in patients who cannot tolerate clofazimine. Also used as a second-line treatment in combination with clarithromycin, ofloxacin, and clofazimine in patients with rifampin-resistant leprosy.

Ofloxacin (Floxin)

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Ofloxacin is a pyridine carboxylic acid derivative with broad-spectrum bactericidal effect. It is used in single-lesion paucibacillary leprosy. Also used as a second-line treatment in combination with clarithromycin, minocycline, and clofazimine in patients with rifampin-resistant leprosy.

Clarithromycin (Biaxin (DSC))

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Clarithromycin is a macrolide antibiotic used to treat various bacterial infections. Used as a second-line treatment in combination with minocycline, ofloxacin, and clofazimine in patients with rifampin-resistant leprosy.

Follow-up

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Media Gallery

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 sensory loss with curled 5th digit, from 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, MD, 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 map showing worldwide prevalence of leprosy in 2017. Courtesy of the WHO.
2018 leprosy treatment guidelines. Courtesy of the WHO.
Map of countries reporting rifampicin resistance in leprosy between 2009 and 2015. Courtesy of the WHO.
2018 WHO guidelines for treatment of drug-resistant leprosy. Courtesy of the WHO.
2018 guidelines for single-dose rifampicin. Courtesy of the WHO.

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Table 1. 2018 WHO Leprosy Treatment Guidelines. ^[18]

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

Table 2. 2018 WHO Treatment Guidelines for Drug-Resistant Leprosy. ^[18]

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