POD in Leprosy

HENDRA GUNAWAN
Department of Dermatology and Venereology
Faculty of Medicine Universitas Padjadjaran/
Hasan Sadikin Hospital Bandung
All About Leprosy
Old Disease and New Challenges
Pontianak, October 19th – 20th, 2019

 Mechanisms of neuropathy
 Clinical manifestation of deformity
 POD
 Examination of peripheral nerves
 Video examination of peripheral nerves
 Self-care of POD
Outline

Introduction
 Leprosy or Hansen’s disease
 Afffects the skin & nerve tissues
 M. leprae  possess neurotropism and
causes neuropathy  DEFORMITIES.

The Indicator of Leprosy
Control Program
“New Cases of G2D”
< 5%

Sumber: Data dan Informasi Profil Kesehatan Indonesia, Kemenkes RI, Maret 2019
New Cases Great 2 Disability in Indonesia (2018)

Deformity
Disability
Handicap
WHO

Terminology
Deformity (impairment)
Disease producing changes in the structure and
functioning of certain parts of the body.
 Facial disfigurement
 Eye damage
 Shortening of fingers & toes
 Contractures
 Ulcers

Terminology
Disability
An impairment (primary or secondary) that makes
it difficult or impossible for the affected person to
carry out certain activities.
 Affecting manual dexterity
 Personal care
 Mobility

Terminology
Handicap
Persistently disabled persons experience many
disadvantages that limit or prevent them from
fulfilling their normal role in society.
 Unemployment
 Economic and physical dependence
 Social disintegration

Interventions that are aimed at preventing
the occurrence of a new deformity or disability
not already present at the time when the
disease is diagnosed.
Terminology
Prevention of Disability (POD)

Gerhard
Armauer
Hansen
Identification of bacterium
M. leprae in 1873
as the causative agent of
leprosy.

“First bacterium disease in human”

M. leprae
Peripheral neuropathy
Primarily  Schwann cells

Neuropathy 
nerve damage
Deformity & Disability

Infiltration M. leprae
to peripheral nerves
Leprosy reaction

Leprosy Reaction Inflamation
PERIPHERALNEUROPATHY
Peripheral nerves edema

Leprosy Reaction
Tipe 1 Tipe 2
Reversal
Reaction ENL

Tipe 1
• PB & MB
• Type 4 Hs
• Existing lesions
show change
Tipe 2
• MB
• Type 3 Hs
• Erythematous
nodules
Leprosy Reaction

SENSORY
NEUROPATHY
Perception
of stimuli
MOTOR
NEUROPATHY
Voluntary
muscle
movement
AUTONOMIC
NEUROPATHY
Involuntary
organ
activity

IMPORTANT !
Monitoring of nerve function

• Caused with direct invasion
of nerve by M. leprae
Primary
• Complication due to
primary disorder
Secondary

• Caused with direct invasion
of nerve by M. leprae
Primary
• Hypesthesia/anesthesia
• Claw hand
• Xerosis

• Complication due to
primary disorder
Secondary
• Contracture
• Skin ulcers

TINGKAT KECACATAN
KUSTA (WHO, 1998)
TINGKA
T
MATA TANGAN/KAKI
0 Tidak ada kelainan mata Tidak ada cacat akibat kusta
1 Ada kelainan mata, tetapi
tidak terlihat
Anestesi, kelemahan otot
(Tidak ada cacat yang terlihat)
2 Lagoftalmus Ada cacat yang terlihat

Persentase Kecacatan
Profil Kecacatan Pasien Baru Kusta
di Poliklinik Morbus Hansen
RS Dr. Hasan Sadikin Bandung
Dengan Cacat
Tidak Cacat
n = 231 kasus

JENIS KECACATAN PADA MATA
Normal Lagoftalmus

0
5
10
15
20
25
30
35
40
Jenis Kecacatan pada Tangan
Kontraktur Claw hand Atrofi otot Pseudomutilasi Ulkus

26.09 26.09
17.39 17.39
1.2
CATEGORY 1
Jenis Kecacatan pada Kaki
Pseudomutilasi Ulkus Kontraktur Drop foot Claw toes

Upaya Pencegahan
Kecacatan
Penemuan dini pasien
Pengobatan adekuat
Pemeriksaan rutin saraf
Deteksi dini reaksi
Penanganan reaksi
Istirahat & latihan
Perawatan diri
Kerjasama

PEMERIKSAAN RUTIN
SARAF TEPI:
PERABAAN SARAF TEPI
PEMERIKSAAN FUNGSI SARAF

PROSEDUR
UMUM
•Pemeriksa berhadapan dengan pasien
•Perabaan dilakukan dengan tekanan ringan
•Pada saat meraba saraf, perhatikan:
•Apakah ada pembesaran?
•Apakah kiri dan kanan sama besar?
•Bagaimana konsistensinya?
•Apakah ada nyeri atau tidak?

n. aurikularis magnus
Untuk melihat n. aurikularis
magnus dekstra, pasien
diminta untuk menolehkan
kepala ke kiri semaksimal
mungkin (hiperekstensi).

Jari pemeriksa meraba saraf yang menyilang m.
sternokleidomastoideus. Dengan tekanan ringan, saraf
tersebut digulirkan sambil melihat ekspresi pasien

Prosedur yang sama untuk melihat saraf sebaliknya

• Tangan kanan pemeriksa
memegang lengan kanan
bawah pasien dengan posisi
siku ditekuk sehingga
lengan pasien rileks.
n. ulnaris

n. ulnaris
• Lengan kiri pasien: dengan jari telunjuk dan tengah
tangan kanan pemeriksa mencari sambil meraba
saraf di dalam sulkus ulnaris
 lekukan antara tonjolan tulang siku (olekranon)
dan epikondilus medialis

Dengan tekanan ringan, saraf tersebut digulirkan ke atas
sambil melihat ekspresi pasien. Prosedur yang sama untuk
saraf sebaliknya.
n. ulnaris

n. peroneus communis
• Pasien diminta duduk rileks.
• Pemeriksa duduk di depan
pasien dengan tangan kanan
memeriksa kaki kiri pasien dan
sebaliknya.

Pemeriksa meletakkan jari telunjuk pada pertengahan betis
bagian luar pasien sambil meraba ke atas sampai
menemukan caput fibula.

Setelah menemukan caput fibula,
pemeriksa meraba saraf 1 cm ke arah belakang

Dengan tekanan ringan, sambil melihat ekspresi pasien

n. tibialis posterior
Dengan jari telunjuk, pemeriksa meraba saraf di bagian
belakang bawah maleolus medialis.

Tangan kiri pemeriksa memeriksa saraf kiri dan tangan kanan
pemeriksa memeriksa saraf kanan (posisi
tangan menyilang)

PEMERIKSAAN RUTIN
FUNGSI SARAF
 Diagnosis dini kerusakan saraf
 Dilakukan pada setiap kunjungan
 Apabila ditemukan adanya defisit pada
fungsi saraf  penilaian yang teliti dan
periodik.

1 •Mata
2 •Tangan
3 •Kaki
Pemeriksaan dilakukan secara
sistematis dan berurutan
Fungsi sensorik dan
motorik

Fungsi motorik n. fasialis
Pasien diminta memejamkan mata
Dilihat dari depan/samping apakah mata
tertutup sempurna atau tidak  diukur dan dicatat

Fungsi sensorik n. ulnaris
& medianus

& medianus
Letakkan tangan pasien di meja atau paha.
Jelaskan pada pasien apa yang akan dilakukan.

& medianus
Pemeriksa memberikan sentuhan ringan dari ujung ballpoint
pada telapak tangan. Pasien diminta untuk menunjuk tempat
sentuhan.

& medianus
Tes dilakukan dengan mata terbuka  mata tertutup
Bila tidak dapat menunjukkan ≥ 2 titik  gangguan.

Fungsi motorik

PERAWATAN DIRI
A •Mata
B •Tangan
C •Kaki

Is it difficult for you to close your eyes
properly?
Do you often have red eyes?
If “yes” to one or both:
You need to take care of your eyes
to prevent damage

Keep your eyes in good condition
• Dust, sunlight, & dryness can damage eyes.
• Close your eyes often to protect them.
• Make it a regular habit.

During the day:
• Wear glasses or a hat.
• Ladies can wear a shawl or scarf that can be pulled
over the face.
• Be careful of flies; chase them away with a fan.

At night:
• Sleep under a net or blanket.
• Tie a cloth loosely over your eyes, to keep out dust
and insects.

• If your eyes are itchy, do NOT rub them.
• Pull your eye closed by stretching the skin at the side
of your eyes.
• Use eye drops.

Dirt
• Clear away with clean cloth
• Eye drops

• Check your eyes in a mirror every morning & evening.
• If you cannot  ask a friend to check them for you.
• Your eyes are red  a health worker or a doctor.

Do you have loss of feeling in your hands?
Do you often have wounds on your hands?
You need to take care of your hands
to keep them healthy and prevent more
damage

Perawatan Tangan
• Gunakan tangan yang dapat merasa
• Perhatikan benda panas, kasar & tajam
• Bekerja tidak lama & berganti
Hindari luka
• Merasa
• Melihat
• Mempelajari
Perawatan
• Selama 20 menit
• Melunakan kulit yang keras
• Menggunakan kepingan
• Menggunakan minyak
Merendam &
Menggosok

Don’t hold your hands near the fire

If you can’t feel normally,
your hands can easily be injured:
• Use gloves or a cloth to hold hot pots
• Wrap cloth around the handles of tools

Danger
Rough handles
Thorns
Hammers
Action
Make handles smooth
Put padding on handles
Use pliers for holding nails

Check hands for:
· Heat
· Redness
• Wounds

The skin on your hands can become dry
and cracked:
• Every morning & evening, soak your hands in
water for 20 minutes
• After soaking, scrape off hard skin with
something rough
• Rub some oil on your hands.

Do you have any weakness or stiffness in the
hands or fingers?
If “yes” :
• You can help to reduce stiffness by doing
the exercises
• You can take care of weak hands yourself
 Develop the exercise habit

BEST ADVICE
Exercise 3 times every day:
• Morning - Do each exercise 10 times
• Noon - Do each exercise 10 times
• Night - Do each exercise 10 times

Do you have loss of feeling in your feet?
Do you often have wounds on your feet?
You need to take care of your feet
to keep them healthy and prevent more
damage

 Foot care:
From moment diagnose
& treatment started
Injury care
Skin care
Walking
care

 Knowing a risk  first action in preventing injury
 Avoid injury to their feet all through the day
 Early signs of impending wound:
Heat
 A warning  tissue is beginning to break down
Redness and swelling
 If unable to feel the heat of an inflamed area so
inspection is also essential

Check Feet For
Heat
Redness
 Wounds

Things that make feet tired are, walking:
 Too fast
 Too far
 On hard things

• Body weight  transferred to
the feet
• The load is borne by the heel 
shifted to the ball
• The amount of forces 
• Length of stride
• Speed of walk
• Distance of walk
PRECIPITATING
FACTORS
Repetitive
walking
Courtesy: Yawalkar, SJ. Leprosy for Medical
Practitioners and Paramedical Workers

Etiopathogenesis
Tissue Breakdown
in Leprosy

Normal Body Response to Tissue Stress
Deep tissue is fatigued by
repetitive stress & release
chemical messengers
Chemical messengers
stimulate free nerve
endings
Damaged foot responds
to rest, recovers and
continues to function
Brain receives messages as a
pain and starts actions to
rest damaged foot

Response to Tissue Stress
in Patient with Leprosy
Deep tissue is fatigued by
repetitive stress  chemical
messengers
Damaged nerves
can’t relay message to brain
Fatigue becomes too great
and tissue cells are destroyed
Substances released from
destroyed tissues cause edema
Edema  blocks the supply of
nutrients and oxygen
Starved tissue breaks down,
releases more chemical
messengers
Skin bursted and ulcer
is formed
No action is taken to rest
damaged foot
walking
walking

 Walking  stressed  wounds
 Walking care measures:
1. Restricting walking
2. Reducing walking
3. Protective footwear

Things that make feet tired are, walking:
 Without shoes or sandals
 With bad shoes or sandals
Bad shoes or sandals are:
 Not soft
 Too tight
 Broken
This is how can
get wounds

 Reduce the pressure up to 25%
 Not wear shoes for more than 5-6
hours at a time
 Inspect feet every time they take off
their shoes
• Avoid injury to their feet all the day
 always wear protective footwear

Protective Footwear
• Cushion against
walking pressures
Soft insole
• Prevent pierced by
sharp objects
Hard outer
sole
• Fits well with straps
over the forefoot
• Not rub against toes
Upper
portion

 Damaged nerves  control sweating (-)  dry skin
 tensile stress in the epidermis  cracks
 Keep skin soft and supple:
Daily soaking the affected part in water
(20 min every day)
Apply any cooking oil or emolient creams to the
skin and soles

 Calluses  scraped
Object with a rough surface
(scraper, pumice stone)
Self-care kit
Soaking Scraping Oiling

• Soak feet for 20 minutes
• Scrape away hard skin
• Rub oil on the feet

Perawatan Kaki
• Merendam dalam air
• Mengoleskan minyak
• Memakai selalu alas kaki
Cracks & fisura
• Tidak dipecahkan
Bula
• Membersihkan dengan sabun dan air
• Istirahat
Ulkus
• Oil massage
Paralisis

Walk slowly and try to REST often
Take care of wounds

POD
Pasein
Keluarga
Tenaga
Kesehatan
Masyarakat
LSM
Pemerintah
Dokter
(IKFR)
Keberhasilan
POD

Medicines for leprosy can cure the
disease completely.
We have the power
to prevent disability

Referensi
 Pedoman Nasional Program Pengendalian Penyakit Kusta Kemenkes RI,
2012.
 Preventing Disability in Leprosy Patients, Jean M. Watson, London, 1986.
 Prevention of Disabilities in Patients with Leprosy. A practical Guide, WHO,
Geneva, 1993.
 Essential Action to Minimise Disability in Leprosy Patients, Jean M Watson,
London, 1986.
 Petunjuk Pengisian Form Pencegahan Kecacatan, Prgram P2 Kusta Provinsi
Jawa Timur, 20016.
 Tindakan Penting Untuk Mengurangi Resiko Cacat pada Penderita Kusta,
Kemenkes RI 1998.
 Website WHO
 Dokumentasi Divisi Dermatologi Infeksi Departemen Ilmu Kesehatan Kulit dan
Kelamin FK Unpad/RS Hasan Sadikin, Bandung

POD in Leprosy

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