Leprosy

Clinical Description

Leprosy 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).

Signs and Symptoms

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.

Treatment Objective

• 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 (Months)

MB PB

Adult Rifampicin 600mg once a month 12 6

Clofazamine 300 mg once a month and 50 mg daily

Dapsone 100 mg daily

Children 10 to 14 Years

Rifampicin 450 mg once a month 12 6

Clofazamine 150 mg once a month and 50 mg daily

Dapsone 50 mg 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 Drug Resistant Leprosy regimens

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 reactions

The 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 1-2 weeks and tell him to return at once should the reaction become 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.