What is the recommended treatment for leprosy?

Treatment of Leprosy

The recommended treatment for leprosy is multidrug therapy (MDT) consisting of rifampin, dapsone, and clofazimine, with the specific regimen determined by the classification of the disease as either paucibacillary or multibacillary leprosy. 1, 2, 3

Disease Classification and Treatment Regimens

Multibacillary Leprosy

• Standard WHO MDT regimen:
  • Rifampin: 600 mg once monthly (supervised)
  • Dapsone: 100 mg daily (self-administered)
  • Clofazimine: 300 mg once monthly (supervised) and 50 mg daily (self-administered)
  • Duration: 12-24 months until all signs of clinical activity are controlled 1, 2

Paucibacillary Leprosy

• Standard WHO MDT regimen:
  • Rifampin: 600 mg once monthly (supervised)
  • Dapsone: 100 mg daily (self-administered)
  • Duration: 6 months 2, 4

Pediatric Dosing

• Dapsone: 1-2 mg/kg/day (maximum 100 mg) 1, 2
• Clofazimine: 2-3 mg/kg/day (maximum 100 mg daily) 1
• Rifampin: Dosage adjusted based on weight

Monitoring During Treatment

Clinical Monitoring

• Regular assessment of skin lesions and nerve function
• Monitoring for leprosy reactions (Type 1 and Type 2)
• Assessment for drug adverse effects

Laboratory Monitoring

• For patients on dapsone: Complete blood count to monitor for hemolysis, especially in G6PD-deficient patients 1
• For patients on clofazimine: Monthly ECGs when possible, especially when combined with other QTc-prolonging medications 1

Potential Adverse Effects

Dapsone

• Hemolytic anemia (especially in G6PD deficiency)
• Methemoglobinemia
• Peripheral neuropathy
• Agranulocytosis (rare)
• Hypersensitivity syndrome ("sulfone syndrome") 1

Clofazimine

• Skin pigmentation (75-100% of patients)
• Ichthyosis (8-20%)
• Gastrointestinal intolerance (40-50%)
• QT interval prolongation 1

Rifampin

• Hepatotoxicity
• Orange-red discoloration of body fluids
• Drug interactions due to CYP450 induction

Alternative Regimens

For Patients Unable to Tolerate Standard MDT

• Monthly rifampin, moxifloxacin, and minocycline (RMM) regimen has shown efficacy with fewer side effects, particularly avoiding clofazimine-related skin pigmentation 5

For Drug-Resistant Cases

• Second-line agents may include:
  • Fluoroquinolones (ofloxacin, moxifloxacin)
  • Minocycline
  • Clarithromycin 6, 3

Special Considerations

HIV Co-infection

• Standard MDT regimens are recommended
• Closer monitoring for adverse effects and drug interactions
• May require longer treatment duration 1

Leprosy Reactions

• Type 1 (Reversal) Reactions: Corticosteroids
• Type 2 (Erythema Nodosum Leprosum): Thalidomide (with appropriate precautions) or corticosteroids 1

Treatment Duration and Follow-up

• Paucibacillary: 6 months of MDT
• Multibacillary: 12-24 months of MDT
• Borderline tuberculoid patients: Continue dapsone for 3 additional years after clinical control
• Lepromatous patients: Continue dapsone for 10 years to life after clinical control 2

Pitfalls to Avoid

1. Monotherapy: Never treat with a single drug due to high risk of resistance development 3, 7
2. Premature discontinuation: Complete the full course of therapy to prevent relapse
3. Inadequate monitoring: Regular follow-up is essential to detect reactions and adverse effects
4. Missing drug resistance: Consider drug resistance if clinical deterioration occurs during appropriate therapy 2
5. Ignoring reactions: Prompt recognition and treatment of leprosy reactions is crucial to prevent nerve damage and disability

The evidence strongly supports multidrug therapy as the cornerstone of leprosy treatment, with high efficacy and acceptable safety profiles when properly monitored and managed.