About the many aspects of the proper treatment of ENL

Leprosy Mailing List – September 10^th, 2010

Ref.:   About the many aspects of the proper treatment of ENL

From: G. Warren, Sidney, Australia

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Dear Salvatore,

I refer to Pieter Schreuder’s message dated LML Sept. 2nd, 2010.  I would like it to get to the younger folk some of whom throw prednisolone around like sweets, as it is was the answer to everything and do not realise the complications and how much it can shut down a lot of the bodies natural ability to cope with  inflammation etc.

For the sake of those who are involved in the care of severe erythema nodosum leprosum (ENL) reaction especially in light skinned patients, I would like to add to Dr Schreuder’s comments:-  Yes, clofazimine at doses as he suggests (starting with 300mg per day and till off all steroids) is highly successful.  I also worked in Thailand and we had dozens of patients who had been treated with prednisolone for ENL, before they came to us and we eventually got them off the prednisolone and stabilised on clofazimine with all ENL controlled and stable till completely bacteria negative.  However the light skinned patients often do not like the dark colour that develops but if it is properly explained and they see others who can confirm that the colour will fade later they will usually accept it especially if they do have severe ENL.

In those days we usually gave clofazimine as mono-therapy – it was before MDT recommendations -  and I was involved in some of the original drug trials of clofazimine and if I only had one drug to treat leprosy I would use clofazimine.  I have never seen a patient become resistant to it even when given as mono-therapy for a long period, and  although I understand resistant bacilli have been developed in laboratories they, as far as I know, have never developed in a patient (*).

Working in third world countries for many years I also know the problems of prednisolone and know that many patients are given it unnecessarily.  This concerns me as I have seen many patients who have died because of the use or was it abuse, of prednisolone.  In countries where it can be bought  without a doctors prescription we find that patients self medicate, with prednisolone because it “makes them feel good”, and we have had many patients with undesirable complications.  Patients that I consider could have been treated with less or no prednisolone.  Some have died after they officially finished prednisolone because within the period needed for their own adrenal function to be restored, they developed some other medical condition that should have been treated with more prednisolone but that was not given and the patient died.  

Personally I have learnt how to manage most ENL without prednisolone and do so if at all possible, because many patients live where it is not easy to access good medical care in the prolonged period needed to restore their normal immune ability after the prednisolone has finished.  An important point is to find, diagnose and treat any other medical condition that may in fact be responsible for or contribute to the problem of the ENL (eg anaemia and parasites).  In many patients the adequate treatment of tuberculosis or malaria  or chronic typhoid will “cure” the ENL, and minimise the risk for post treatment complications.

Hope that this helps some adapt to difficult circumstances.

Grace  Warren

Previously Adviser in leprosy and reconstructive surgery for The Leprosy Mission in Asia.

*(note by S. Noto)

Titia Warndorff-van Dieden, “Clofazimine-resistant leprosy, a case report”

International journal of leprosy and other mycobacterial diseases, volume 50, number 2 June 1982