Leprosy

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ICD10 CODE: A30.0

A chronic infectious disease caused by Mycobacterium leprae / Hansens bacillus - an acid-fast bacillus. It mainly affects the skin, peripheral nerves and mucous membranes. It is transmitted from one person to another via the respiratory tract (possibly, very rarely, through broken skin). It is classified into paucibacillary (PB) or Multibacillary (MB) Leprosy.

Clinical features

 

• Pale or reddish patches on the skin (The most common sign of leprosy)
• Loss or decrease in feeling in the skin patch
• Numbness or tingling of the hands or feet.
• Weakness of the hands, feet or eyelids
• Painful or tender nerves
• Swelling or lamps in the face or earlobes
• Painless wounds or burns on the hands or feet

Case definition

A case of leprosy is a person with clinical signs of leprosy who requires chemotherapy.

Diagnosis of leprosy

Diagnosis of Leprosy must be based on careful clinical examination of the patient and when necessary, backed by bacteriological examination

Leprosy is diagnosed by finding at least one of the three cardinal signs:

• Hypopigmented patches with definite loss of sensation in them
• Thickened or enlarged peripheral nerves, with loss of sensation and/or weakness of the muscles supplied by those nerves
• The presence of acid-fast bacilli in a slit skin smear

Classification of leprosy

Paucibacillary (PB) leprosy: 1-5 patches

Multibacillary (MB) Leprosy: More than 5 patches

Differential diagnosis

• Hypopigmentation e.g. birthmark, early vitiligo
• Fungal infections of the skin
• Other nodular conditions, e.g. Kaposi’s sarcoma, neurofibromatosis, secondary syphilis
• Other causes of peripheral nerve damage, e.g. diabetes mellitus
• Psoriasis, molluscum contagiosum

Investigations

• In most cases, a definite diagnosis of leprosy can be made using clinical signs alone
• At referral centre: stain slit skin smears for Acid Fast Bacilli (AFB)
• Skin biopsies NOT recommended as a routine procedure

Management

Multi-drug therapy (MDT) for leprosy is presented in the form of various monthly dose blister packs. The same drugs are used for both PB leprosy and MB leprosy, with special packs for children.

Summary of Treatment of Leprosy 

PB Leprosy	MP Leprosy
Rifampicin	Rifampicin
Dapsone	Dapsone
Clofazimine	Clofazimine
All for 6 months	All for 12 months

Recommended treatment (drugs and their dose)

Category	Drug	Dosage and frequency	Duration
			PB	MB
Adult	Rifampicin	600 mg once a month	6 months	12 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	6 months	12 months
	Clofazimine	150 mg once a month, 50 mg daily
	Dapsone	50 mg daily
Children <10 years old or <40 kg	Rifampicin	10 mg/kg once month	6 months	12 months
	Clofazimine	6 mg/kg once a month and 1 mg/kg daily
	Dapsone	2 mg/kg daily
Steroids for treatment of severe leprae reactions Prednisolone 40 mg once daily in morning Treat for 12 weeks in PB and 24 weeks in MB Reduce dose gradually by 10–5 mg once every 2 weeks (PB) or 3 weeks (MB)				RR

 

Note: 

In patients co-infected with HIV, do not use dapsone. In PB leprosy, substitute dapsone with clofazimine in appropriate doses

Health worker should directly observe that the medicines taken once a month are actually swallowed

Treatment durations longer than 12 months and steroids for leprae reactions should only be prescribed by specialists at referral centres

Lepra reactions: sudden inflammation (pain, redness, swelling, new lesions, loss of nerve function) in skin lesions or nerves of a person with leprosy. They can occur before, during or after MDT completion.

Severe leprae reaction (Type 2) are also known as Erythema Nodosum Leprosum (ENL or Type 2 reactions)

All patients should undergo rehabilitation and physiotherapy

Counsel patient on: need to complete treatment, presence of residual signs after completion of treatment

Presence of residual signs or post-treatment reactions is NOT an indication to re-start the treatment

Refer to the National Tuberculosis and Leprosy Programme (NTLP) manual 2016 for more details

Prevention

Early diagnosis of cases and effective treatment

Screening of contacts of known patients

Administration of Single dose rifampicine in contacts of leprosy patients to prevent contacts of leprosy patients from developing leprosy disease

Rifampicine dose used in contacts of leprosy patiients

Age/weight	Rifampicin single dose
15 years and above	600mg
10-14years	450mg
Children 6-9years (weight 20kg)	300mg
Children 20kg ( 2years)	10-15mg/kg

BCG vaccination may be helpful

Disability due to Leprosy

Leprosy commonly causes physical disabilities which generate social stigma. Disability refers to an impairment (primary or secondary) that makes it difficult or impossible for the affected person to carry out certain activities, e.g. affecting manual dexterity, personal care, mobility and communication behavior

Definitions of disability:

In the hands and feet:

• Grade 0 = No anesthesia, no visible deformity or damage
• Grade 1 = Anaesthesia, but no visible deformity or damage
• Grade 2 = Visible deformity or damage present

In the eyes

• Grade 0 = no eye problem due to leprosy, no evidence of visual loss
• Grade 1 = eye problem due to presence of leprosy, but vision not severly affected as a result (6/60 or better, can count fingers at six meters)
• Grade 2 = severe visual impairment (vision worse than 6/60; inability to count fingers at six meters), lagophthalmos, iridocyclitis, corneal opacities

Management of Disability in the hand and feet

Resting of the affected limb in the acute phase can be aided by splinting, especially at night

Soaking and oiling for about 30 minutes every day of dry skin helps to prevent cracking and preserves the integrity of the epidermis.

Use of a clean dry cloth to cover the wounds and walking as little as possible and walk slowly, taking frequent rest. Passive exercise and stretching to avoid contractures and strengthen muscle weakness

Use of a rough stone to smoothen the skin on the feet or palms,

Protective foot wear (MCR Sandals) al, the time. For insensitive feet and protective appliances like gloves for insensitive hands

Eye complications due to Leprosy

These include

• Lagophthalmos: whole spectrum
• Corneal hypoesthesia: with/without corneal ulcers
• Acute iritis and scleriti
• Chronic iritis and iris atrophy

Treatment & Management of eye complications

Medical therapy for eye complications due to Leprosy- use of the topical antibiotics and topical steroids. It is strongly recommended that an ophthalmologist and a trained leprologist, if available, be included in the treatment of Hansen disease with ocular manifestations.