Leprosy Treatment & Management

Updated: Aug 24, 2018
  • Author: Darvin Scott Smith, MD, MSc, DTM&H; Chief Editor: Michael Stuart Bronze, MD  more...
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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.

Table 1. Multidrug Therapy Plan Recommended by the WHO (Open Table in a new window)

Type of Leprosy

Daily, Self-Administered

Monthly Supervised

Months of Treatment

Paucibacillary

Dapsone 100 mg

Rifampicin 600 mg

6

Single-lesion paucibacillary

Rifampicin 600 mg,

Ofloxacin 400 mg,

Minocycline 100 mg

N/A Single dose

Multibacillary

Dapsone 100 mg,

Clofazimine 50 mg

Rifampicin 600 mg,

Clofazimine 300 mg 

12

Pediatric

Dapsone 2 mg/kg,

Clofazimine 1 mg/kg

Rifampicin 10 mg/kg,

Clofazimine 6 mg/kg

Same as in adults

Also see the chart below:

WHO Multidrug Therapy Regimens. Courtesy of WHO, L WHO Multidrug Therapy Regimens. Courtesy of WHO, Leprosy Elimination, http://www.who.int/lep/mdt/en/, accessed April 15, 2016.

US regimens emphasize the use of rifampin, which is the most bactericidal drug used to treat leprosy.

Table 2. US Recommendations for Multidrug Therapy [15] (Open Table in a new window)

Type of Leprosy Daily, Self-Administered Monthly Supervised Months of Treatment
Paucibacillary

Dapsone 100 mg,

Rifampicin 600 mg

N/A 12
Single-lesion paucibacillary

Dapsone 100 mg,

Rifampicin 600 mg

N/A 12
Multibacillary

Dapsone 100 mg,

Rifampicin 600 mg,

Clofazimine 50 mg

N/A 24

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. [16] Prednisolone is believed to minimize pain and acute inflammation. The recommended initial dose is prednisolone 40 mg daily.

Observations of increasing resistance in patients treated for leprosy have been reported in Southeast Asia, notably in Vietnam. [17] The drug most commonly found to be resistant is dapsone, often in the context of prior exposure or treatment attempts with monotherapy. Although drug resistance is an ongoing concern, it is difficult to assess in this slow-growing organism. In a study of M leprae strains from South America, few of 230 strains subjected to molecular drug-susceptibility analysis were drug-resistant. Of the 230 strains, 3 were identified as clinically relapsing and were found to be resistant by genetic testing; 2 of the 3 were dapsone-resistant; and 1 was dapsone-resistant and rifampin-resistant using genetic testing for point mutation. [18]

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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 restoration  [10]

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

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Consultations

Consultations may include an orthopedic surgeon, dermatologist, neurologist, psychiatrist, and physical therapist, based on the needs of the individual patient.

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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%. [12]

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. [12] Treatment includes prednisolone, clofazimine, or thalidomide. Erythema nodosum leprosum reaction is seen in the image below.

Patient with multibacillary leprosy showing subseq Patient with multibacillary leprosy showing subsequent erythema nodosum leprosum reaction. Santa Clara, California. Courtesy of D. Scott Smith, MD.

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

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.

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