What is the recommended treatment for Hansen disease?

Treatment of Hansen Disease (Leprosy)

The recommended treatment for Hansen disease is multidrug therapy (MDT) using combinations of dapsone, rifampin, and clofazimine, with regimen selection based on disease classification as paucibacillary or multibacillary. 1, 2

Disease Classification and Treatment Selection

Determine disease classification before initiating therapy:

• Paucibacillary disease (tuberculoid leprosy): characterized by one or few hypoesthetic skin lesions with palpably enlarged nerves 3
• Multibacillary disease (lepromatous leprosy): characterized by multiple nodular skin lesions, sometimes with nasal and eye involvement 3
• Diagnosis is confirmed by skin biopsy/smear showing acid-fast bacilli, clinical findings, and molecular testing (rpoB and hsp65 gene amplification) 4

Standard Multidrug Therapy Regimens

WHO-Recommended MDT (First-Line)

For multibacillary disease:

• Dapsone + rifampin + clofazimine for 12-24 months 1, 2
• This combination has reduced global disease prevalence but carries adverse effects that may impact adherence 2
• Clofazimine is available only as an investigational drug through the National Hansen's Disease Program in the United States 1

For paucibacillary disease:

• Dapsone + rifampin (without clofazimine) 1

Alternative Monthly RMM Regimen (Emerging First-Line Option)

Monthly rifampin, moxifloxacin, and minocycline (RMM) should be strongly considered as first-line therapy, particularly for multibacillary disease:

• Dosing: Monthly administration for 12-24 months 2
• Superior adherence profile: In a US case series of 10 patients (9 multibacillary, 1 pure neural), 100% completed treatment without interruptions 2
• Improved safety: No skin hyperpigmentation (unlike clofazimine) and no significant adverse effects reported 2
• Rapid clinical response: All patients showed rapid improvement of skin lesions 2
• The US National Hansen's Disease Program should consider RMM as first-line therapy based on clinical evidence 2

Other Alternative Agents

For patients unable to tolerate standard regimens:

• Moxifloxacin, ofloxacin, minocycline, or clarithromycin can be substituted 1

Management of Immunologic Reactions

Continue antibacterial therapy during type 1 (reversal) and type 2 (erythema nodosum leprosum) reactions, which may occur before, during, or after treatment: 1

Type 1 (Reversal) Reactions:

• Corticosteroids are the primary treatment 1
• One patient with pure neural leprosy and reversal reaction successfully completed RMM regimen 2

Type 2 (Erythema Nodosum Leprosum) Reactions:

• Treatment options include corticosteroids, thalidomide, pentoxifylline, TNF inhibitors, and T cell inhibitors 1
• Choice depends on clinical manifestations and severity 1

Treatment Monitoring

Monitor treatment response using:

• Clinical improvement of skin lesions 2
• Nasopharyngeal PCR for M. leprae rpoB gene copies (should decrease by 6 months of therapy) 4
• Assessment for peripheral neuropathy progression 5
• Evaluation for eye involvement and nasal structure damage 3

Critical Pitfalls to Avoid

• Do not delay treatment: Early detection and treatment are crucial to prevent irreversible peripheral neuropathy, weakness, and disabilities 5
• Do not discontinue therapy during immunologic reactions: Antibacterial therapy should usually be continued 1
• Do not overlook contact tracing: Implement close contact prophylaxis and community awareness measures 5
• Do not assume low transmission risk: The disease is transmitted via aerosol droplets and broken skin-to-skin contact, with the nine-banded armadillo serving as a reservoir in the United States 1, 5

Special Considerations for US Practice

• Hansen disease is emerging in the United States due to migration, particularly from Haiti and endemic regions 4
• Endemic areas include Texas, Louisiana, Hawaii, and California 3
• All cases should be reported to notifiable disease databases 4
• Molecular diagnostic tools (PCR for rpoB and hsp65 genes) facilitate diagnosis and follow-up 4