Leprosy

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Clinical DescriptionLeprosy is a chronic infection usually caused by the acid-fast bacilli mycobacterium leprae which has a unique tropism for peripheral nerves, skin and mucus membranes of the upper respiratory tract. Leprosy is classified into Paucibacillary (tuberculoid) and Multibacillary (lepromatous).

 

Clinical Features

Paucibacillary (PB) Leprosy is characterized by: 

• 5 lesions or less
• Lesions that are asymmetrically distributed
• Definite loss of sensation on the lesions
• Only ONE nerve trunk is enlarged and Negative Slit Skin Smear (SSS).

Multibacillary (MB) is characterized by

• More than 5 lesions
• Symmetrically distributed lesion
• Some degree of loss of sensation on the lesions
• Many nerve trunks are enlarged and Positive Slit Skin Smear.

TreatmentTREATMENT OBJECTIVES

• To cure the patient (using multi drug therapy).
• To render patient non-infectious and thus control the spread of leprosy.
• To prevent the development of multi drug resistant leprosy.

Drugs used in leprosy as recommended by WHO are a combination of rifampicin, clofazimine and dapsone (MDT). The duration of treatment for PB leprosy is 6 months and 12 months for MB leprosy.

Recommended Leprosy Treatment Regimens

Age group	Medicine	Dosage and frequency	Duration (in Months)
			MB	PB
Adult	Rifampicin	600mg once a month	12	6
	Clofazamine	300mg once a month and 50mg daily
	Dapsone	100 mg daily
Children 10 to 14 Years	Rifampicin	450 mg once a month	12	6
	Clofazamine	150mg once a month and 50mg daily
	Dapsone	50mg daily
Children <10 years old or <40kg	Rifampicin	10 mg/kg once month	12	6
	Clofazamine	100 mg once a month, 50 mg twice weekly
	Dapsone	2 mg/kg daily

Treatment for Drug-Resistant Leprosy

• Leprosy patients with rifampicin resistance are treated using at least two of the following second-line drugs: clarithromycin, minocycline, or a quinolone (oxfloxacin, levofloxacin or moxifloxacin), plus clofazimine daily for 6 months, followed by clofazimine plus one of the second-line drugs daily for an additional 18 months. In case of rifampicin plus oxfloxacin resistance, a quinolone should not be chosen; therefore, the recommended regimen is clarithromycin, minocycline and clofazimine for 6 months followed by clarithromycin or minocycline plus clofazimine for an additional 18 months.

Recommended Treatment Regimens for Drug Resistant Leprosy

Resistance Type	Treatment
	First 6 months (daily)	Next 18 months (daily)
Rifampicin Resistance	Oxfloxacin 400 mg* + minocycline 100 mg + clofazimine 50 mg	Oxfloxacin 400 mg OR minocycline 100 mg + clofazimine 50 mg
	Oxfloxacin 400 mg* + clarithromycin 500 mg + clofazimine 50 mg	Oxfloxacin 400 mg* + clofazimine 50 mg
Rifampicin and oxfloxacin resistance	Clarithromycin 500 mg + minocycline 100 mg + clofazimine 50 mg	Clarithromycin 500 mg OR minocycline 100 mg + clofazimine 50 mg

Treatment of ReactionsThe term reaction is used to describe the appearance of signs and symptoms of acute inflammation in the lesions of a patient with leprosy.   

Treatment for mild reactions 

• Continue anti-leprosy treatment, do not lower the dosage.
• Give an analgesic (e.g Aspirin).
• If there is nerve tenderness, rest the affected limb (sling or splint the arm)
• See the patient again after 2 weeks and instruct them to return if the reaction becomes more severe.

Treatment of severe Reaction

• Continue anti-leprosy treatment.
• Start treatment with steroids (prednisolone)- no other drugs are effective. 40mg daily for 2 weeks, 30mg daily for 2 weeks, 20mg daily for 2 weeks, 15mg daily for 2 weeks, 10mg daily for 2 weeks, 5mg daily for 2 weeks.

Acute Dapsone Allergic Reaction Symptoms/Signs:

• Itching, rash, exfoliative dermatitis or Stevens-Johnson syndrome
• Refer urgently to Leprosy Control Assistant
• Stop Dapsone
• Then observe

Treatment

• Give Antihistamines, steroids or hospitalize depending on severity.