What are the indications for steroid use in patients with leprosy?

Indications for Steroid Use in Leprosy

Steroids are indicated in leprosy for treating Type 1 (reversal) reactions and Type 2 reactions (erythema nodosum leprosum), as well as for acute nerve function impairment, with prednisolone being the primary agent used. 1

Primary Indications

Type 1 (Reversal) Reactions

• Prednisolone is indicated when Type 1 reactions present with swelling of existing skin and nerve lesions, particularly in borderline or tuberculoid leprosy patients, often occurring soon after chemotherapy initiation 1
• Severe reactions or those with neuritis require large doses of steroids and hospitalization 1
• The mechanism involves enhanced delayed hypersensitivity response to residual infection following reduction in antigenic load 1

Type 2 Reactions (Erythema Nodosum Leprosum)

• Steroids are indicated for ENL, which occurs mainly in lepromatous patients (approximately 50% in the first year of treatment) 1
• Clinical features warranting steroid therapy include: fever, tender erythematous skin nodules, malaise, neuritis, orchitis, albuminuria, joint swelling, iritis, epistaxis, or depression 1
• Severe cases with pustular/ulcerative skin lesions require hospitalization and steroid therapy 1
• The underlying mechanism is vasculitis with intense polymorphonuclear infiltrate and elevated circulating immune complexes 1

Acute Nerve Function Impairment

• Steroids are indicated for early nerve function impairment to prevent permanent disability, though evidence shows only 60-70% of patients respond to treatment 2, 3
• Surgical decompression of swollen nerve trunks may be needed alongside steroid therapy 1

Optimal Steroid Regimens

High-Dose Long-Duration Protocol (Preferred)

• Start with prednisolone 60 mg daily, tapered over 20-28 weeks 4, 5
• This regimen shows significantly lower recurrence rates (16-24%) compared to shorter or lower-dose regimens 4, 5
• The high-dose 20-week regimen is superior to 12-week regimens, with only 24% requiring additional steroids versus 46% on short courses 5

Alternative Low-Dose Protocol

• Prednisolone 40 mg daily tapered over 22 weeks, or 30 mg daily tapered over 20 weeks 4, 5
• Associated with higher recurrence rates (31-48.3%) compared to high-dose regimens 4, 5
• Contains 50% less total steroid but shows marginally inferior outcomes 5

Inadequate Regimens to Avoid

• 12-week courses are insufficient, with 46% of patients requiring additional steroids 5
• Short-duration therapy leads to significantly higher treatment failure rates 5

Clinical Response Patterns

Expected Outcomes

• 76% of patients show improvement in combined clinical reaction severity scores with steroid treatment 2
• Skin manifestations respond best, with 78.9% showing improvement 2
• Only 35% of patients with sensory nerve damage and 50% with motor nerve damage show improvement, highlighting the difficulty in reversing established neuropathy 2
• Cytokine profiles (IFN-gamma, IL-12, iNOS) show minimal change at day 7 but significant decreases by day 28 of steroid therapy 3

Recurrent Reactions

• 36% of patients require additional steroids due to recurrence of skin and/or nerve reactions 2
• Some patients maintain high cytokine production even at 180 days post-treatment, indicating persistent inflammatory activity 3
• Recurrent reactions represent a major treatment challenge and may require prolonged or combined immunosuppressive therapy 2

Critical Management Principles

Continuation of Anti-Leprosy Treatment

• Anti-leprosy chemotherapy should be continued during reactional states and steroid therapy 1
• Steroids suppress the reaction but do not replace antimicrobial treatment 1

Monitoring and Adverse Effects

• Strict pre-steroid investigation protocols are essential to screen for contraindications 4
• Significant adverse effects attributable to steroids occur and must be monitored 2
• When azathioprine and dapsone are given together, significant anemia develops, making this combination not recommended 2
• Diabetes and peptic ulcers are potential complications requiring surveillance 6

Common Pitfalls to Avoid

Inadequate Treatment Duration

• Do not use steroid courses shorter than 20 weeks for Type 1 reactions, as this leads to treatment failure rates exceeding 45% 5
• Reactions persist over many months and require long courses 5

Premature Treatment Cessation

• Do not stop steroids abruptly when early improvement occurs, as only 60-70% ultimately respond and many require extended therapy 2, 3
• Some patients show continuing inflammatory activity even after 180 days of treatment 3

Failure to Recognize Non-Responders

• 22% of patients show no change and 1.1% deteriorate despite steroid treatment 2
• 65% of patients with sensory nerve damage and 50% with motor nerve damage do not improve, requiring alternative approaches 2
• Long-term evidence does not show significant benefit for long-standing nerve function impairment or mild sensory impairment 6

Inappropriate Combination Therapy

• Azathioprine does not improve outcomes when added to steroids and causes significant anemia when combined with dapsone 2
• Azathioprine is not recommended for routine treatment of leprosy reactions 2