Leprosy Mailing List – June 19, 2019
Ref.: (LML) Type 1 reaction: downgrading versus reversal reactions
From: Kabir Sardana, Delhi, India
Dear Pieter,
It is unfortunate to see that type 1 reaction has been labelled as reversal reaction even though we have seen many cases of Type 1 downgrading reaction where patients present with a reaction localised to the skin with little neuritis and with lesions of the lower spectrum in conjunction with the reaction.
These patients present with reaction, and are not on treatment that makes upgrading unlikely. Also, this reaction is mentioned in all the major textbooks (Hastings, Jopling Handbook of leprosy, Dharmendra Leprosy, Leprosy by Khanolkar and numerous published articles).
While the reason for downgrading is not clear, which is the case for most reactions, that is no reason for this to be ignored. The reasons are that while we see these cases (1/week) removing this from the lexicon of Type 1 reaction makes this difficult to stratify for clinicians - as where would you place a patient with erythema, oedema of lesions suggestive of a lower pole with no neuritis?
Most importantly I have found them much easier to treat than upgrading - probably because suppressing a heightened CMI (upgrading reaction) is much more difficult! Of course, a cytokine analysis would be ideal (which we are doing) but the biopsy is also useful for diagnosing them and has been shown by many studies in the past. The so-called rising BI is not always possible to confirm as patients tend to present with reactions and the preceding primary lesion is difficult to discern.
Thus, possibly if Type 1 downgrading is added this can help to decide the type 1 reaction that easier to treat.
Dr. Kabir Sardana
Prof. Of Dermatology
Dr RML Hospital 7 PGTMER
Delhi – 110001
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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