Leprosy Mailing List – January 27 , 2014
Ref.: (LML) Facial Erythematous Patches
From: Grace Warren, Sidney, Australia
Dear Pieter,
Yes I would also like to comment on the two lesions shown in the letter from Dr Rao. There were I think both originally stated to be PB leprosy and treated accordingly.
In one when the lesion returned after the MDT has ceased the patient was treated with steroids only. I am afraid that will not eliminate the bacilli which, as Dr Barretto says, are hiding in the blood vessels . Yes the steroids reduce the swelling and make it look better but also reduce the effectiveness of the body’s ability to eliminate the bacilli.
I would never treat any leprosy patient who has a reaction with steroids without other antileprosy drugs. In fact I always increase the MDT by as many months as they have had the steroid. Yes the steroid reduces the signs of inflammation - and makes the patient feel better, but it also allows the bacilli freedom of movement and multiplication as the T-lymphocytes are not so effective against the bacilli when steroids are around.
Also the appearance of that lesion is certainly not the normal appearance for a true PB - there is too much edge and one suspects that there are more lesions elsewhere. I always taught the PB was less than 6 lesions yes and must have normal sensation, BUT if the lesions were scattered on several areas of the body - e.g. one on arm, one of leg one on face etc then it was better and safer to treat as MB initially. I have seen too many of these so called relapses which I think could easily be prevented.
This type of lesion is also not uncommon in Eastern Asia - i.e. the lighter skins often develop a diffuse infiltration that is very difficult to see any edge and define one, but if allowed to persist will eventually be true highly infectious LL/.BL disease.
Yes the second lesion of the nose certainly looks more BT than Indeterminate. So although it may technically be PB it is far safer to treat as MB.
With many years of experience I teach that it is far better to overtreat initial lesions if there is any chance of the lesions being MB and if there is any reaction treat again with full MDT. For those who tend to reaction I like increasing the clofazamine that often is as effective and not as dangerous as steroids as I found many patient in Asian countries go and buy the steroids themselves because it is freely available in their country and it makes them feel better. I have seen so many people with undesirable effects, even death, from OVERuse of steroids.
If steroids were commenced before I see the patient, I like to grade them off the steroids by using clofazamine in higher dosage and then increase the total amount of MDT by the total number of months that the steroids were used. Please make sure the patient does not have some other metabolic or infectious disease that could be reducing his immune potential! We must make every effort to prevent relapses as each one of these tends to spread the message we cannot treat leprosy adequately.
All the best to those who really care for their patients long term welfare,
Grace Warren
Previously Superintendent Hong Kong Leprosarium ( 1960-75)
Also Previously Adviser in Leprosy and Reconstructive Surgery for the Leprosy Mission in Asia ( 1975-1995)
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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