Ungrading and downgrading reactions; do these concepts help us?

Leprosy Mailing List – May 3^rd, 2012

Ref.:   Ungrading and downgrading reactions; do these concepts help us?
From: J A da Costa Nery, Rio de Janeiro, Brazil

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Dear Salvatore,

It´s always a pleasure to follow these reports, so we can think upon them.  In my whole life studying leprosy, these nomenclatures [upgrading and downgrading reactions] always bothered me.  I find them, as a clinician, very hard to distinguish on a daily basis.

I don’t really know if these concepts help us in the programme and, not all doctors know how to use that kind of nomenclature while treating reactional episodes.  The discussion on appearance of either upgrading or downgrading type 1 reaction [type 1 reaction is also commonly referred to as reversal reaction or RR] is very relevant to the knowledge on leprosy in the state of art.  Nevertheless, such a goal is more likely to be achieved by basic researchers, by means of immunologic tests; not by clinicians.  Moreover, it is not always possible, given that cellular proliferation and activation tests are not deemed as a golden standard assessment.  On the other hand, histopathology is also helpful for the definition of RR, although such examination is not very useful to evaluate the characteristic of such a reaction (either upgrading or downgrading). 

It’s always good to hear new opinions so we can discuss.  Lately I´ve been studying cases of relapse in leprosy, and I´ll watch out for these type 1 reactions, which are treated with long term corticosteroids,  can they be included in the downgrade?

We have a large experience with a number of RR cases per year, and our most relevant concern relates to the long-term use of corticosteroids and risk of disability. 

Best wishes,

Dr. José Augusto da Costa Nery
Fiocruz