Management of Neuritis in Leprosy
For leprosy patients with neuritis, initiate high-dose oral prednisolone (60 mg daily) with a gradual taper over 5-6 months while continuing multidrug therapy, as this regimen prevents neuropathy progression and reduces the need for additional corticosteroids. 1, 2, 3
Initial Assessment and Grading
Grade the severity of neuritis to guide treatment intensity:
- Grade 1 (Mild): Minimal pain and paresthesias without interference in daily activities 1
- Grade 2 (Moderate): Neuropathic pain and weakness without gait limitation, causing some interference with activities 1
- Grade 3-4 (Severe): Weakness limiting walking, muscle atrophy, or rapidly progressive symptoms requiring aids for self-care 1
Perform nerve conduction studies and electromyography to differentiate mononeuropathy versus polyneuropathy and assess the pattern of nerve damage 1. High-resolution ultrasound with Color Doppler can assess nerve size and endoneural blood flow to identify active inflammation 1.
Corticosteroid Treatment Regimens
Standard Regimen for Most Cases
Start prednisolone 60 mg daily (single morning dose) and taper by 10 mg each month over 5 months 3. This approach demonstrates significant improvement in clinical and electrophysiological parameters, with reduction of nerve conduction block in 42% of patients and low reaction prevalence (8.3%) after treatment completion 3.
A 5-month corticosteroid regimen is significantly superior to a 3-month regimen, with fewer patients requiring additional corticosteroids during follow-up 4, 5. The evidence shows moderate quality support for this extended duration approach 4.
Severe or Rapidly Progressive Neuritis
For Grade 3-4 neuritis with severe symptoms, consider pulse methylprednisolone 1 gram IV daily for 3-5 days, followed by high-dose oral prednisone with prolonged taper 1. This aggressive approach is warranted when nerve function impairment is rapidly progressing or when significant motor weakness is present 2.
Adjunctive Pain Management
Add neuropathic pain medications as needed:
- Gabapentin, pregabalin, or duloxetine for neuropathic pain control 1
- Analgesics for acute pain during reactional states 2
These agents address the pain component while corticosteroids target the inflammatory process.
Management of Type 1 Reactions (Reversal Reactions)
When neuritis occurs with Type 1 reactions (common in borderline or tuberculoid leprosy soon after starting chemotherapy), large doses of steroids should always be used if severe or if neuritis is present 2. Continue anti-leprosy multidrug therapy throughout the reaction 2. Consider surgical decompression of swollen nerve trunks in severe cases with nerve trunk involvement 2.
Refractory Cases
For patients not responding adequately to prednisone (requiring ≥40 mg/day chronically to control symptoms):
Cyclosporine A at 5 mg/kg per day for 12 months with gradual dose reduction is effective in controlling chronic neuritis, improving sensory impairment, muscular force, and pain 6. This immunosuppressive approach reduces anti-nerve growth factor antibodies and provides an alternative when corticosteroids alone are insufficient 6.
For severe, rapidly progressive cases not responding to standard therapy, consider IVIG or plasma exchange 1.
Monitoring and Expected Response
Clinical improvement should occur within days to 3 weeks with appropriate therapy 7. Monitor:
- Sensory function using Semmes-Weinstein monofilament examination 6
- Motor strength assessment 6
- Pain levels (spontaneous and palpation-related) 6
- Nerve conduction studies to document electrophysiological improvement 3
Serological markers (TNF-α, antibodies to PGL-1, LAM, ceramide, S100B) show variable responses to steroid treatment, with levels typically falling 60-67% after one month of prednisolone therapy 8. However, these markers are primarily research tools rather than routine clinical monitoring parameters.
Critical Pitfalls to Avoid
Do not use short-duration steroid courses (less than 5 months) as they result in significantly higher rates of treatment failure and need for additional corticosteroids 4, 5. The evidence clearly demonstrates that 3-month regimens are inadequate compared to 5-month courses 4.
Do not delay treatment initiation, as delays beyond 2 weeks are associated with severe neurological deficits and poor outcomes 7. Early aggressive treatment within hours to days of symptom onset provides the best chance for nerve function recovery 7.
Continue multidrug therapy throughout reactional states and neuritis treatment 2, 3. Stopping anti-leprosy medications during reactions is a common error that can lead to treatment failure.
Long-Term Prognosis
Peripheral neuropathy in leprosy is a significant predictor of long-term damage 1. With appropriate corticosteroid treatment, most clinical parameters show significant improvement 3. However, moderate-quality evidence indicates that for longstanding nerve function impairment (6-24 months duration) or very mild sensory impairment, corticosteroids may not show superior long-term benefit over placebo at 12 months 4, 5. This underscores the critical importance of early intervention before permanent nerve damage occurs.
Relapse rates during corticosteroid dose reduction can reach 50-60%, necessitating careful monitoring during the taper phase 7. Maintain vigilance for recurrent symptoms and be prepared to increase steroid doses if nerve function deteriorates during tapering.