Leprosy reactions: diagnosis and
management
Two types of reactions
Type 1 or reversal reaction
Cell-mediated immunity
Local signs
Long duration
Type 2 or ENL reaction
Humoral immunity
Systemic signs
Short episodes, but often chronic recurrence.
Severity
Mild Severe
Red raised skin plaques Ulcerating skin lesions
Red, tender Painful or tender nerves
subcutaneous nodules Recent ( 6 mts) NFI
Enlarged, non-tender Reaction lesions in the
nerves face
Severe oedema
Involvement of other
organs.
Type 1 Reaction
(1)
Type 1 Reaction
(2)
Type 1 Reaction (3)
Type 1 Reaction (4)
Type 1 Reaction (5)
Type 1 Reaction (6)
Type 1 Reaction (7)
ENL Reaction (1)
ENL Reaction (2)
ENL Reaction (3)
ENL Reaction (4)
ENL Reaction: Iritis
Making the diagnosis
History
Physical examination
Skin signs
Nerve palpation
NFA – sensory or motor impairment?
Systemic signs (edema, fever, other organs)
Criteria for sensory and motor impairment
Criteria for reaction and severe neuritis.
Management of nerve damage
Medical
Surgical
Supportive.
Medical management
NFI ‘recent’ or ‘old’
Corticosteroids – prednisolone
WHO recommends 12-week course
Evidence suggests longer course is needed
for MB patients (24 weeks)
High-dose clofazimine in ENL
Thalidomide drug of choice for ENL in men.
Prednisolone regimens
Adults
PB: starting dose 40 mg daily, duration 12 weeks
MB: starting dose 40 mg daily, duration 24 weeks
Children
30 mg daily for one week, then alternate days,
tapering as above (12 weeks).
Patients over 15 years
PB: MB:
40 mg od for 2 weeks 40 mg od for 4 weeks
30 mg od for 2 weeks 30 mg od for 4 weeks
20 mg od for 2 weeks 20 mg od for 4 weeks
15 mg od for 2 weeks 15 mg od for 4 weeks
10 mg od for 2 weeks 10 mg od for 4 weeks
5 mg od for 2 weeks 5 mg od for 4 weeks
Total: 16 weeks Total: 24 weeks
Children up to 15
30 mg od for 1 week
30 mg alternate days for 1 week
25 mg alternate days for 2 weeks
20 mg alternate days for 2 weeks
15 mg alternate days for 2 weeks
10 mg alternate days for 2 weeks
5 mg alternate days for 2 weeks
Total: 12 weeks
Contraindications
Acute or chronic untreated bacterial or parasitic
infection, e.g.
TB
Corneal ulcer
Worm infestation
Scabies
Fungal infection
Current peptic ulcer or recent history of
haematemesis or melaena
Past history of psychosis or endogenous depression.
Relative contraindications
Age under 15 or over 60
Diabetes mellitus
Hypertension
Glaucoma
Pregnancy
Lack of cooperation
Mature cataract
Suspected peptic ulcer
Steroid side effects – major
Side effect Cases (401) Controls (414)
Diabetes 0.7% 0.2%
Peptic ulcer 0.5% 0.2%
Infections 0.7% 1.2%
Psychosis 0 0
Glaucoma 0 0
TB 0 0
Richardus et al., TRIPOD trials
Steroid side effects – minor
Side effect Cases (401) Controls (414)
Moon face 3% 2%
Acne 2% 0.7%
Fungal infections 1% 0
Gastric pain 18% 12%
Richardus et al., TRIPOD trials
Surgical management
Different neurolysis techniques available
Indications
Nerve pain not responding to steroids
Nerve abscess
NFI not responding to steroids
Benefit to be established through controlled
trial.
Neurolysis
Supportive management
Analgesics – not aspirin or other NSAIDs
Splinting
Rest.
Comments and Questions.
