About the many aspects of the proper treatment of ENL

Leprosy Mailing List – September 12^th, 2010

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

From: A Pongtiku, Jayapura, Papua, Indonesia

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Dear Dr Noto,

Thank you very much for bringing the issue of chronic ENL and steroid dependent ENL.  Thank you very much also to the experts that have commented about this important issue.  I remember one senior dermatologist saying that these are among the most difficult problems in treating leprosy patient.

In Indonesia for steroid dependent ENL, we used prednisolone tapering off and substituted with clofazimine high dose 3 x100 mg for 2 months and continued 2 x 100 mg for 2 months and 1 x 100 mg for 2 months.  It should be noted that the effect of clofazimine will be evident after 1 month of therapy; so we should think for prednisolone when tapering off.  Prednisolone is still needed for at least a month, in our protocol for adult case, we start 40 mg and tapering off every two week.  In Papua, Indonesia, many triggered factors for ENL are present like malaria, dental problems, psychological problems, anaemia, under-nutrition.  

I have treated few successful cases with the above reported protocol including 2 cases with steroid depended AIDS due to ENL reaction.  We tapered off prednisolone faster (decreased dose of prednisolone every 5 days) and at the same time added clofazimine.  Accurate case holding and home visits are necessary to support the patient.

It is important to think about BI (Bacterial Index) when BI is high more than 4 +, it is more possible to develop ENL.  In few ENL reactions that developed after treatment with MDT for 12 months, we found still high Morphological Index (solid type of bacteria).

I agree with Dr Warren (LML Sept. 10^th, 2010) about prednisolone is dangerous if not managed well.  Some patients died because of self administration of this drug.  Prednisolone can be easily bought in drug store without prescription in Indonesia.  Many leprosy patients feel secure/better with prednisolone so they may go for self administration. 

Now, together with a dermatologist and I, we are treating a leprosy patient with a steroid dependent ENL reaction of more than a year used  and already finished MDT a  year ago.  We used the protocol of prednisolone tapering off and substitution with clofazimine.  Because of still  BI 3+ and 4+ as well as MI 70%, we also retreated with MDT.  However complication of gastrointestinal upset/vomiting occurred at fourth week (3 times hospitalization).  We then stopped high clofazimine.  We tried to give MDT after a week but vomiting appeared again.  Now, we used methylprednisolone the patient looks better.  We still wait until stable condition and continue to retreat with other anti leprosy.

Finally, I would like to say:  "when we recommend the use of steroid for the management of patients in reaction we/medical staff must be responsible for tapering off ".

Thank you very much,

Dr. Arry Pongtiku, MHM

National Consultant for Leprosy and Yaws in Papua and West Papua, Indonesia

Netherlands Leprosy Relief Indonesia