What are the latest treatment guidelines for leprosy?

Latest Treatment Guidelines for Leprosy (Hansen's Disease)

The current standard treatment for leprosy consists of multidrug therapy (MDT) with dapsone, rifampin, and clofazimine, with treatment duration of 6 months for paucibacillary disease and 12-24 months for multibacillary disease, as recommended by the World Health Organization and CDC. 1

Disease Classification and Diagnosis

Proper classification is essential for determining the appropriate treatment regimen:

• Paucibacillary (PB): Includes tuberculoid and indeterminate forms with limited skin lesions and negative skin smears
• Multibacillary (MB): Includes lepromatous and borderline forms with multiple skin lesions and positive skin smears

Diagnosis is confirmed through:

• Demonstration of acid-fast bacilli in skin or dermal nerve biopsies
• Clinical presentation with characteristic skin lesions and thickened nerves 1

Standard Treatment Regimens

Paucibacillary Leprosy (6 months)

• Rifampin: 600 mg once monthly (supervised)
• Dapsone: 100 mg daily 1, 2

Multibacillary Leprosy (12-24 months)

• Rifampin: 600 mg once monthly (supervised)
• Dapsone: 100 mg daily
• Clofazimine: 50-100 mg daily plus 300 mg once monthly (supervised) 1, 3

Pediatric Dosing

• Dapsone: Correspondingly smaller doses based on weight 2
• Clofazimine: 2-3 mg/kg/day (maximum 100 mg daily) 3, 1

Alternative Regimens

For single skin lesion PB leprosy, a single-dose regimen may be considered:

• Rifampin: 600 mg
• Ofloxacin: 400 mg
• Minocycline: 100 mg 4, 5

However, this regimen should only be considered after careful evaluation, as longer follow-up data is still needed to confirm long-term efficacy 5.

Management of Drug Resistance

If dapsone resistance is suspected (clinical and bacteriological relapse during treatment):

• Confirm resistance clinically if no response to supervised therapy for 3-6 months
• Switch to alternative drugs based on sensitivity testing 2
• Consider adding additional agents such as ofloxacin or minocycline 6

Management of Reactions and Complications

Immunologic reactions are common complications that require prompt management:

• Continue anti-leprosy treatment
• Add corticosteroids (prednisone/prednisolone) for severe reactions or neuritis
• Provide analgesics for pain management
• Consider surgical decompression of swollen nerve trunks if needed 1

Monitoring During Treatment

Regular monitoring is essential:

• Complete blood count to detect hemolytic anemia and methemoglobinemia (especially with dapsone)
• Liver function tests
• Monthly ECGs when possible, especially when using clofazimine (risk of QT prolongation) 3, 1
• G6PD screening before initiating dapsone therapy, particularly in at-risk populations 3
• Skin smears and neurological assessments to monitor treatment response 1

Important Considerations

• Clofazimine side effects: Skin discoloration (75-100% of patients), ichthyosis (8-38%), and gastrointestinal issues (up to 50%) 3
• Dapsone side effects: Hemolysis (especially in G6PD-deficient patients), methemoglobinemia, and gastrointestinal disturbances 3, 2
• Treatment duration: After completing the recommended course, tuberculoid and indeterminate patients should continue dapsone for an additional 3 years, borderline tuberculoid patients for 5 years, and lepromatous patients for 10 years to life 2

Recent Advances

Research is ongoing to develop shorter treatment regimens and improve outcomes 4, 6. However, until more robust evidence is available, the standard WHO multidrug therapy remains the gold standard for leprosy treatment 5.