What is the treatment of choice for Type 2 lepra reactions?

Treatment of Choice for Type 2 Lepra Reaction

Corticosteroids are the treatment of choice for Type 2 lepra reactions.

Understanding Type 2 Lepra Reaction

Type 2 lepra reaction, also known as erythema nodosum leprosum (ENL), is a Th2-mediated type III hypersensitivity reaction that occurs in leprosy patients, particularly those with lepromatous leprosy or borderline lepromatous leprosy. It is characterized by:

• Tender, erythematous nodules on the face, arms, and legs
• Constitutional symptoms (fever, malaise)
• Potential for nerve damage and disability
• Can occur during or after completion of multi-drug therapy

Treatment Options and Evidence

First-line Treatment: Corticosteroids

Corticosteroids are the mainstay of treatment for Type 2 lepra reactions due to their potent anti-inflammatory effects. They effectively suppress the immune complex-mediated inflammation that characterizes Type 2 reactions 1.

For severe Type 2 reactions:

• High-dose oral or intravenous glucocorticoids
• Initial dosing typically at 0.75-1 mg/kg body weight/day of prednisolone equivalent
• Gradual tapering as symptoms improve

Second-line Treatments

1. Thalidomide:

   • Drug of choice for severe atypical lepra reactions due to its anti-TNF-α properties 2
   • Particularly effective but has significant limitations due to teratogenicity
   • Cannot be used in women of childbearing potential

2. Clofazimine:

   • Can be used as a steroid-sparing agent
   • Often used in combination therapy with corticosteroids
   • Initial dosage of 300 mg daily (100 mg three times daily) 3
   • May require maintenance therapy for 6 months to prevent recurrence

Treatment Algorithm

1. Assess severity of Type 2 reaction:

   • Mild: Limited cutaneous involvement without systemic symptoms
   • Moderate: More extensive cutaneous lesions with mild systemic symptoms
   • Severe: Extensive cutaneous lesions with systemic symptoms, neuritis, or other organ involvement

2. Initial treatment:

   • For mild-moderate reactions: Oral corticosteroids (prednisolone 30-40 mg/day)
   • For severe reactions: Higher dose corticosteroids (prednisolone 60-80 mg/day)

3. For steroid-dependent or recurrent cases:

   • Add clofazimine (100 mg three times daily)
   • Consider thalidomide in males or non-pregnant females (not of childbearing potential)

4. Tapering strategy:

   • Begin tapering steroids once clinical improvement is observed
   • Taper by approximately 5-10 mg every 2-4 weeks
   • Continue clofazimine for at least 6 months to prevent recurrence

Important Considerations

• Monitor for steroid-related complications (hyperglycemia, hypertension, osteoporosis)
• Thalidomide is absolutely contraindicated in pregnancy due to teratogenicity
• Clofazimine causes skin discoloration, which may be a cosmetic concern
• Recurrent episodes may require longer maintenance therapy

While aspirin, paracetamol (PCM), and other NSAIDs may provide symptomatic relief for pain and fever, they do not address the underlying immunological mechanism of Type 2 lepra reactions and are therefore not considered treatments of choice.