Leprosy (including reactions)

Management Strategy

Since 2018, the World Health Organization (WHO) recommends multidrug therapy (MDT) with rifampicin 600 mg monthly, dapsone 100 mg daily, and clofazimine 300 mg monthly and 50 mg daily for all forms of leprosy to avoid undertreating multibacillary patients misclassified as having paucibacillary disease. This uniform regimen varies in duration depending on the type of leprosy: 6 months for paucibacillary HD and 12 months for multibacillary HD.

The US National Hansen’s Disease Program (NHDP) recommends rifampin 600 mg daily and dapsone 100 mg daily for 12 months for paucibacillary HD and rifampin 600 mg daily, dapsone 100 mg daily, and clofazimine 50 mg daily for 24 months for multibacillary HD. In the US, clofazimine is available only through the NHDP as an investigational drug.

If clofazimine is not available or declined due to skin hyperpigmentation, or if a patient cannot take rifampicin or dapsone, alternative antibiotics are minocycline 100 mg, ofloxacin 400 mg, levofloxacin 500 mg, clarithromycin 500 mg, or moxifloxacin 400 mg, all in daily doses. Rifampicin is often prescribed monthly for patients on prednisone, warfarin, oral contraceptives, and other drugs with metabolism affected by rifampicin. If multidrug therapy is interrupted for any reason, it should be resumed when possible for the remaining months required to complete the recommended duration of multidrug therapy.

Multidrug therapy should be continued during reactions. Mild type 1 reversal reactions and type 2 reactions are treated with non-steroidal antiinflammatory drugs . For a severe type 1 reversal reaction with acute neuritis, particularly involving the face, aggressive therapy with systemic steroids is started to prevent potentially irreversible nerve damage. Prednisone 0.5–1 mg/kg daily should be started and a steroid-sparing immunosuppressive drug such as methotrexate (10–20 mg weekly) should be added promptly since high doses of steroids are required to control a type 1 reversal reaction. Immunosuppressant therapy is needed for 3–6 months or longer depending on the patient’s response.

A severe type 2 reaction also responds to prednisone 0.5–1 mg/kg daily and often requires a slower taper of 6 months or longer. Thalidomide, a known teratogen, is the drug of choice for men and for women who are postmenopausal, surgically sterile, or using appropriate contraceptives. The initial thalidomide dose ranges from 100–200 mg nightly depending on the type 2 reaction severity. The dose is decreased slowly over several months to a maintenance dose of 50–100 mg nightly to prevent recurrences. Other drugs for type 2 reaction include methotrexate , azathioprine , infliximab , and etanercept. Lucio phenomenon is treated with prednisone, low-dose aspirin , and wound care.

Leprosy clinics are usually free and at WHO clinics compliance is monitored by attendance to witness the intake of monthly medications. After completion of MDT, PB cases are screened once and MB cases annually for 5 years. Household contacts, who lived with a leprosy patient during the 3 years before HD therapy, should have one screening examination and if negative no follow-up exam is needed. WHO advises that a single 600 mg dose of rifampicin may be used as leprosy preventive treatment for contacts of leprosy patients (adults and children aged 2 years and above) after excluding leprosy and tuberculosis disease, and in the absence of other contraindications.

For leprosy neuropathy and neuritis , gabapentin, pregabalin, or amitriptyline alleviate the pain.