LL patients may have no obvious skin lesions and no changes in sensation for years

Leprosy Mailing List – January 24^th, 2012 

Ref.:    LL patients may have no obvious skin lesions and no changes in sensation for years
From:  G. Warren, Sidney, Australia

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Dear Dr Noto,

It was good to see Dr Lockwood’s letter (LML Jan. 20^th, 2012) regarding the “Elimination” in Brazil, and her acknowledgement that recognition of leprosy cases will continue for many decades.

One report states that in at least one country there is an incidence of 50% of graded 2 disability in new cases at diagnosis.  This surely means that the clinicians just do not know early leprosy. Unfortunately as, I have often said before, I believe that this is largely due to the WHO statement that to be diagnosed as leprosy the patient needs an anaesthetic skin patch!  I have worked in many countries (27) and find so many variants in early presentation, partly racial but, in some groups the highly infectious LL patients may have no obvious skin lesions and may have no changes in sensation for twenty years and, even then many of them do not have any anaesthesia; though they may have altered sensory perception.  In the same way as Most diabetics do not have anaesthetic feet; they feel each step as it hits the ground but they may not feel a cut or even a broken bone causes no pain.  Yes, I have seen WHO consultants refuse to register patients with positive skin smears because they had no anaesthesia.  Also I have seen many “Primary persistent neuritic” leprosy patients not registered because they have no skin patch.

Surely we need to somehow get these recognised so that we do get  more accurate figures.  The present statements that leprosy Elimination is progressing is causing reduction in available funds.  The present figures really do not give any idea of how much leprosy is spreading.  In India there are hundreds of children being diagnosed now.  Is it really changing or just that people are now looking and revising their strategies, for which I am very thankful.

Can these new Statistics from India inspire others to try and do something similar?  What can be done to modify that Definition of leprosy as published in the WHO guide to Elimination.  That definition is certainly not the one in most reliable Text books on Leprosy which state the patient needs at least one of three clinical signs, which are patches, nerve involvement or positive skin smears.  While that definition stands many early patients will not be diagnosed at a time when it is possible and easy to eliminate the disease before serious deformity has been caused.

Keep it up Brazil and may others follow your lead and may we proceed to a more practical approach to the control of this disease.  The use of that word elimination makes Governments try and forget that it is still a problem and can easily flare up again to a major problem unless constantly looked for.  I teach my students “What you do not look for you will never see”.  Let’s try and get everyone looking for leprosy again.

Grace Warren,

Previously advisor for the Leprosy Mission in Asia. (1975-1995)