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close this bookClinical Guidelines and Treatment Manual (Médecins Sans Frontières, 1993)
close this folderChapter 4 - Skin conditions
View the document(introductory text...)
View the documentDermatology
View the documentImpetigo and other purulent dermatoses
View the documentHerpes simplex, Herpes zoster
View the documentScabies
View the documentLeg ulcer
View the documentFungal infection
View the documentAnthrax
View the documentOther skin conditions
View the documentEndemic syphilis, Yaws & Pinta
View the documentLeprosy

Leprosy

A chronic infectious disease caused by the Hansen bacillus (Mycobacterium leprae) and affecting the skin, mucosae and peripheral nerves.
Humans are the only significant reservoir of infection.

Clinical features

COMPLETE CLINICAL EXAMINATION

- Patient must be undressed.

- The entire skin surface must be examined.

- Note the appearance of any lesions.

- Test the sensation (fine touch and pin-prick) of the lesions.

- Palpate the main peripheral nerves to detect any hypertrophy.

- Examine peripheral nervous function: motor, sensory and proprioception.

- Examine the nasal mucosa to detect any chronic rhinitis.

MICROBIOLOGICAL EXAMINATION

Ziehl-Nielsen stain
- Scraped incision method to obtain tissue juice but no blood.
Pinch a fold of skin with a Kocher forceps so as to make it bloodless, incise and saape the scalpel blade along the inside of the incision.
· one specimen from the edge of a lesion.
· one from the earlobe.

- Also take a nasal swab.
CLASSIFICATION (RIDLEY-JOPLING SYSTEM) (See table D)


Table

Principles of management

The increasing frequency of strains of M. leprae resistant to dapsone poses a serious threat to leprosy control programs. The strategy of multiple drug therapy must be instituted in order to combat this problem.

It is patients with multibacillary forms of leprosy (BL and LL) who are most exposed to the risk of drug resistance and who are also most infectious to their household contacts.

The treatment of lepromatous leprosy has three objectives:

1. to reduce transmission

2. to cure the patient

3. to prevent the emergence of resistant strains of M. leprae

Patients with tuberculoid leprosy are less infectious but are more likely to suffer paralysis of peripheral nerves. The main objective of their treatment is to preserve function.

Patients under therapy are exposed to the risk of developing severe reactions. For this reason, as well as to ensure compliance, supervision is necessary. The program must be well planned, organized and adequately staffed.

Treatment

"Partially supervised" regimens work best. Daily doses of dapsone can be taken at home by the patient, but monthly doses of rifampicin should be administered by a health worker. The worker must ensure that the patient swallows the medication.

LEPROMATOUS LEPROSY (dispensary)
rifampicin (PO) : 600 mg once per month, supervised
dapsone (PO) : 100 mg daily, at home
clofazimine (PO) : 300 mg once per month, supervised and 50 mg daily, at home

Duration of therapy: 2 years or more, depending upon progress

TUBERCULOID LEPROSY (dispensary - hospital)
rifampicin (PO) : 600 mg once per month, during 6 months
dapsone (PO): 100 mg daily during 6 months (1-2 mg/kg/day)

- rifampicin must always be taken under supervision.

- dapsone may be taken at home. If treatment is interrupted, a full 6 months regimen should be completed after the medication has been discontinued.

REACTIONS

- Either reversal reactions (upgrading: shift towards TT end of spectrum) or erythema nodosum leprosum (ENL).

- Treat with clofazimine(PO): 100 to 300 mg/d

- If severe, use corticosteroids:
prednisone (or prednisolone) PO: 80 mg D1; 75 mg D2; 70 mg D3; 65 mg D4; 60 mg D5...then decrease 5 mg every day.