Wednesday, June 22, 2011

Leprosy Mailing List – May 11th, 2011 
Ref:    Management of Type I reaction (reversal reaction)
From: W. S. Bhatki, Santacruze (E), Mumbai, India


Dear Dr Noto,
Though the standard treatment for management of leprosy reactions is laid down, the same cannot be practiced in all the cases.  The clinicians who actually handle the cases with leprosy reactions have often to decide the line of treatment, based on the response in individual cases.  I report herewith about “Difficulties in management of Type I leprosy reaction with facial lesions”.
I came across three cases (photographs enclosed below) with solitary, medium sized, raised, erythematous, plaque-like anaesthetic facial lesions. The patients received paucibacillary multy-drug therapy (PB/MDT) for 6 months and steroid therapy in tapering doses.  All of them were skin smear negative.  No biopsies were done. The three photographs (enclosed) were taken after these patients were referred to us after completing their course of PB/ MDT, and because of suffering from 1-2 episodes of reaction without satisfactory result while on steroids as described below.
The initial response to prednisolone with daily dose of 40 mg was good as the lesions showed noticeable regression. The dose of prednisolone was tapered by 5-10 mg every 2 weeks.  The lesions recurred with erythema and oedema when the daily dose of prednisolone was brought down to around 15-20 mgthis forced the clinician to raise the daily dose to 30 mg or more.  This phenomenon occurred repeatedly in the cases under reference. 
In the context of fluctuating clinical response, the clinicians often face problems such as:
1.    The total duration of steroid therapy is much more extended beyond the usually advocated period of 12 weeks posing a threat of serious side effects.
2.    The clinicians are often inclined to extend the period of MDT beyond 6 months or sometimes even switch over to multibacillary (MB) MDT.
3.    Due to repeated recurrence of face lesions, the case holding becomes difficult as the patients tend to change the doctors.

Steroid treatment (prednisolone) is still considered the treatment of choice for Type I reaction with the starting daily dose of 30-40 mg.  However, the duration of treatment could be a matter of debate.  I would like to have the opinions and the advice from colleagues on this and the issues mentioned above especially with reference to face lesions which could cause severe psychological distress to the affected persons.
Regards,
Dr. W. S. Bhatki
Maharashtra Lokhita Seva Mandal
Santacruze (E), Mumbai, India

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