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Cutaneous Leprosy
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Cutaneous Leprosy

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Skin manifestations&therapy of leprosy

Skin manifestations&therapy of leprosy

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  • 1. Cutaneous leprosy
    • Leprosy is a chronic granulomatous disease, caused by Mycobacterium leprae, which affects principally the skin and peripheral nervous system
    • Animal reservoirs of leprosy : 9-banded armadillos & chimpanzees
  • 2. Pathophysiology:
    • The areas most commonly affected by leprosy are the superficial peripheral nerves , skin, mucous membranes of the upper respiratory tract, anterior chamber of the eyes , and testes. These areas tend to be cooler parts of the body .
    • Tissue damage is caused by the degree to which cell-mediated immunity is expressed, the extent of bacillary spread and multiplication , the immunologic complications (ie, lepra reactions), and the nerve damage and its sequelae
  • 3.
    • M leprae is an obligate intracellular acid-fast bacillus with a unique ability to enter nerves.
    • The incubation period ranges from 6 months to 40 years or longer. The average incubation period is 2-3 years .
  • 4. Medical Diagnosis of Leprosy
    • The disease is usually diagnosed on the basis of : anesthesia of a skin lesion , thickened nerves , and typical skin lesions .
    • Prodromal symptoms are generally so slight that the disease is not recognized until a cutaneous eruption is present.
    • Temperature is the first sensation that is lost
    • The next sensation lost is light touch , then pain, and finally deep pressure .
    • A hypopigmented macule : the first cutaneous lesion. From this stage, most lesions evolve into the lepromatous, tuberculoid or borderline types.
  • 5. Indeterminate leprosy (IL)
      • This early form causes one to a few hypopigmented, or sometimes erythematous, macules. Sensory loss is unusual.
      • Most cases evolve from this state into one of the other forms, depending on the patient's immunity to the disease.
      • Those with strong immunity may become cured of disease.
      • May persist in this indeterminate form.
      • In those with weaker immunity, the disease progresses to one of the other forms.
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  • 10. Tuberculoid leprosy (TT)
    • Skin lesions :few in number. Usually, one erythematous large plaque is present, with well-defined borders that are elevated and slope down into an atrophic center.
    • Another presentation involves a large asymmetric hypopigmented macule.
    • Neural involvement is common in TT; it leads to tender, thickened nerves
  • 11.  
  • 12. Borderline tuberculoid leprosy (BT)
      • Lesions in this form are similar to those in the tuberculoid form, but they are smaller and more numerous . The nerves are less enlarged,
      • Disease can remain in this stage, convert back to the tuberculoid form, or progress.
  • 13. Borderline borderline leprosy (BB)
      • Cutaneous : numerous , red, irregularly shaped plaques that are less well defined . Their distribution may mimic those of the lepromatous type, but they are more asymmetric .
      • Anesthesia : moderate .
      • Regional adenopathy may be present.
      • Disease may remain in this stage, improve or worsen.
  • 14. Borderline lepromatous leprosy (BL)
      • Lesions : numerous and consist of macules , papules , plaques , and nodules .
      • . Anesthesia : often absent .
      • As with the other forms of borderline leprosy, the disease may remain in this stage, improve, or regress.
  • 15. Lepromatous leprosy (LL)
    • Early cutaneous lesions : pale macules . Later, infiltrations are present, with numerous bacilli. Macular lesions : small , diffuse , and symmetric .
    • The lateral eyebrows are affected by alopecia
    • Lepromatous infiltrations : diffuse, nodules (called lepromas), or plaques. The diffuse type results in the appearance of a leonine facies.
    • Lymphadenopathy ,hepatomegaly Stridor ,hoarseness ,osteomyelitis &Brawny edema .
  • 16.  
  • 17. Skin Biopsy
    • Epidermis
    • Collections of Foamy macrophages in the upper dermis.
    • Around adnexa
  • 18. Case : Clinical details
    • An 8 year old boy presented to clinic with a right Bell’s palsy.
    • In addition it was noted that he had multiple hypo-aesthetic pale patches on the skin.
  • 19. Mouth Drooping corner of mouth Reduced nasolabial fold
  • 20. Right arm Slightly nodular hypopigmented rash
  • 21. Left leg Slightly nodular hypopigmented rash
  • 22. Case
    • A 29 year old man was screened for skin lesions after his father was found to have leprosy
  • 23. Left cheek Raised erythematous plaque over left cheek
  • 24. Lab. Studies:
    • Tissue smear test: An incision is made in the skin, to obtain fluid from a lesion. The fluid is placed on a glass slide and stained by using the Ziehl-Neelson acid-fast method to look for organisms.The bacterial index (BI) is then determined
      • Skin biopsy : for morphologic features and the presence of acid-fast bacilli.
      • Sensory testing : Tactile and temperature sensations should be tested.
  • 25. Lab. Studies:
    • Lepromin testing
      • It indicates host resistance to M leprae. and does not not confirm the diagnosis, but they are useful in determining the type of leprosy.
      • A positive finding indicates cell-mediated immunity,. A negative finding suggests a lack of resistance to disease.
      • To perform this test, bacillary suspension is injected into the forearm. When the reaction is assessed at 48 hours , it is called the Fernandez reaction When the reaction is read at 3-4 weeks , it is called the Mitsuda reaction .
  • 26. Reactions in Leprosy
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  • 31. Medical Classification of leprosy
    • Paucibacillary or PB leprosy .: patients can be cured by
    • treating the patient with two drugs for six months.
    • Multibacillary or MB leprosy : patients can be cured by treating the patient with three drugs for twelve months.
    • How to tell if someone has PB or MB leprosy?
    • Count the skin patches
    • • If you find five patches or less, classify the patient as PB.
    • • If you find more than five patches, classify the patient as MB.
    • When a skin smear is taken
    • • If the skin smear is negative and the patient has five patches or less, classify the patient as PB.
    • • If the skin smear is positive, classify the patient as MB, whatever the number of skin patches.
  • 32.  
  • 33. Therapy of Leprosy Multiple Drug Therapy ( MDT )
  • 34.  
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  • 36. Therapy for lepra reactions
    • Early diagnosis and the timely initiation of anti-inflammatory measures.
    • The possible precipitating factor should be removed MDT should be continued in full dosage without interruption.
    • The principles of treatment : Rest, both physical and mental, with appropriate sedation.
    • Analgesics and anti-inflammatory drugs:
    • Aspirin (acetylsalicylic acid) and corticosteroids
  • 37. Therapy with corticosteroids
    • Type 1 lepra reaction : Prednisolone should be started with a single daily dose of 40–60 mg (maximum 1mg/kg body weight) according to severity.
    • In severe Type 2 lepra reaction : prednisolone should be started at a dose of 20–40 mg/day.
    • Clofazimine : given in doses up to 300 mg daily for one month, and then gradually reduced .
  • 38. THANK YOU