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THE TREATMENT OF LEPROSY (H.D.)
LEPROSY (Hansen’s Disease) AND ITS TREATMENT
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Because of its unique nature, the treatment of Leprosy is not just a matter of destroying certain bacteria in so many “cases” but of dealing with People who have been infected not only by a totally curable disease but also by a society which may be prejudiced by ignorance and superstition . It is essential, therefore, that those involved in the treatment of Leprosy Sufferers, be persons who can exercise compassion, patience, perserverence and understanding. This applies particularly to those “in the field” who meet with the patients in their villages.
“Treatment” in the Past:-
It was not until 1941 that an effective anti-leprosy drug became available following the use of Hydnocarpus Oil in India and China. From as early as (600 B.C.), through the writings of Sushtra, there is evidence of Hydocarpus Oil being used and an Egyptian physician is reported to have used the oil back in ancient times. Modern-day leprologists doubt whether Chaulmoogra Oil (sometimes called Hydnocarpus Oil) had any real effect on leprosy. Certainly, in my own experience in India , in the early 50’s, Chaulmoogra Oil had more of a psychological benefit than physical and it was painful to administer, being a thick oil.
The discovery of Diamino Diphenyl Sulphone (Dapsone DDS) in the early part of th 20th. century, gave new hope for leprosy patients but it was not until 1946 that Robert Cochrane successfully experimented in treating leprosy patients with this drug in an oily suspension which was administered intramuscularly. I had the privilege of meeting this distinguished pioneer in India and worked with his son, Dr. Ian H. Cochrane, in Bangladesh, for 6 years. One year after Cochrane started using DDS in India, Lowe experimented with oral Dapsone in 1947, in Nigeria. Dapsone has two main disadvantages (1) - when used for a long period, it can cause anaemia and (2) - it is bacteriostatic and does not actually kill the bacillus but rather only prevents its multiplication. Because of the emergence of Dapsone-resistant bacilli, it was essential that new and more potent drugs be found and this led to the discovery of Rifampicin, which also is efficaceous against the T.B. bacillus ( very much like M.Leprae).
For thirty years, Dapsone was the main antileprosy drug but, in the early 60’s, Clofazamine (Lamprene) became available and, combined with Dapsone, it proved to be invaluable in the treatment of lepromatous patients. Clofazamine is only slightly bactericidal being mainly bacteriostatic. Browne and Hogerzeil first experimented with Clofazamine in Nigeria and reported encouraging results in 1962. Clofazamine is the only drug used in leprosy treatment which is anti-inflammatory and this means it is most helpful in treating lepromatous patients suffering from Erythema Nodosum Leprosum (ENL) and its toxic side-effects are less than those of Prednisolone. A controversial drug, Thalidomide, is excellent for treating patients with severe ENL, which does not respond to Chloroquin, Aspirin and Prednisolone, providing the patients are male, or females unable to bear children. Thalidomide is used in treating Reaction only in very rare circumstances. It also must be remembered that its use is illegal in some countries. Clofazamine has a few disadvantages in that, being a dye, it causes skin discoloration (darkish blue) also ocular pigmentation.
Multi-Drug Therapy :-
In the early 1970’s a revolutionary new drug - Rifampicin - emerged and this is the main bactericidal drug now used in Multi-Drug-Therapy (MDT) . In the case of the majority of leprosy patients who are “paucibacilliary”, at the Tuberculoid or non-infectious end of the immunological spectrum, Rifampicin (600 mg. per month as a single, supervised dose) is combined with Dapsone (100mg daily) . For those (approx 25% average) at the lepromatous, infectious end of the spectrum , with multibacilliary forms of leprosy, three drugs are used in MDT - Dapsone, Rifampicin and Clofazamine (50 mg. per day) .
The W.H.O - recommended MDT regimen is as follows - Leprosy patients are now classified into Paucibacilliary and Multibacilliary. For both Paucibacilliary and Multibacilliary adult patients, the recommended MDT dosage of Rifampicin is 600mg. once a month. For Multibacilliary leprosy patients, an extra drug - Clofazamine - is prescribed as a supervised dose of 300mg. per month and 50 mg. daily unsupervised. Dapsone is also recommended for both paucibacilliary and multibacilliary adult patients as a dose of 100mg. daily. For children, W.H.O. recommends a monthly dose of Rifampicin at 10mg. / kg. once a month and Dapsone as a daily dose of 1-2 mg. / kg..
Because of the danger of the emergence of drug-resistant leprosy bacilli, treatment must be regular and the costly Rifampicin, administered under supervision. Because of this, teams of Para-medical Workers (PMW’s) personally administer MDT in the field. Patients are permitted to take home their daily doses of Dapsone and Clofazamine but Rifampicin must be administered under supervision. If, for any reason, patients are not able to report to the monthly clinic, it is the responsibility of the PMW to visit the patient in his / her home to see that the Rifampicin capsule is actually consumed.
Especially in very difficult cases and, more particularly, in relation to exacerbated ENL (Erythema Nodosum Leprosum) in Multibacilliary / Lepromatous leprosy, Minocycline at 100 milligrams per day, may also be given, plus Clofazamine 100milligrams a day and Rifampicin 600 milligrams a day at least one hour before taking food. This is prescribed in rare cases, along with Thalidomide (if permitted - it is illegal in some countries) in males or in females unable to bare children. Please note that before prescribing any such medication, you should consult with higher authorities such as The Leprosy Mission, American Leprosy Missions or ILEP, whose addresses are given below. They each have a panel of Consultants who are only too willing to help by giving advice.
Multi-Drug Therapy :-
In the early 1970’s a revolutionary new drug - Rifampicin - emerged and this is the main bactericidal drug now used in Multi-Drug-Therapy (MDT) . In the case of the majority of leprosy patients who are “paucibacilliary”, at the Tuberculoid or non-infectious end of the immunological spectrum, Rifampicin (600 mg. per month as a single, supervised dose) is combined with Dapsone (100mg daily) . For those (approx 25% average) at the lepromatous, infectious end of the spectrum , with multibacilliary forms of leprosy, three drugs are used in MDT - Dapsone, Rifampicin and Clofazamine (50 mg. per day) .
The W.H.O - recommended MDT regimen is as follows - Leprosy patients are now classified into Paucibacilliary and Multibacilliary. For both Paucibacilliary and Multibacilliary adult patients, the recommended MDT dosage of Rifampicin is 600mg. once a month. For Multibacilliary leprosy patients, an extra drug - Clofazamine - is prescribed as a supervised dose of 300mg. per month and 50 mg. daily unsupervised. Dapsone is also recommended for both paucibacilliary and multibacilliary adult patients as a dose of 100mg. daily. For children, W.H.O. recommends a monthly dose of Rifampicin at 10mg. / kg. once a month and Dapsone as a daily dose of 1-2 mg. / kg..
Because of the danger of the emergence of drug-resistant leprosy bacilli, treatment must be regular and the costly Rifampicin, administered under supervision. Because of this, teams of Para-medical Workers (PMW’s) personally administer MDT in the field. Patients are permitted to take home their daily doses of Dapsone and Clofazamine but Rifampicin must be administered under supervision. If, for any reason, patients are not able to report to the monthly clinic, it is the responsibility of the PMW to visit the patient in his / her home to see that the Rifampicin capsule is actually consumed.
Especially in very difficult cases and, more particularly, in relation to exacerbated ENL (Erythema Nodosum Leprosum) in Multibacilliary / Lepromatous leprosy, Minocycline at 100 milligrams per day, may also be given, plus Clofazamine 100milligrams a day and Rifampicin 600 milligrams a day at least one hour before taking food. This is prescribed in rare cases, along with Thalidomide (if permitted - it is illegal in some countries) in males or in females unable to bare children. Please note that before prescribing any such medication, you should consult with higher authorities such as The Leprosy Mission, American Leprosy Missions or ILEP, whose addresses are given below. They each have a panel of Consultants who are only too willing to help by giving advice.
A Leprosy Control Unit
Such a Control Unit may comprise several teams of PMW’s who are men and women with compassionate understanding of the sufferers and who can empathise with them.. PMW’s are responsible for all those in their given targeted area, to determine that medication, related treatment of ulcers, eye problems and health education are provided . Regular Survey is also carried out door to door, village to village, factory to factory, school to school and, in my own experience, in Bangladesh, from Tea Estate to Tea Estate. Each Team of PMW’s is under the oversight of a Supervisor and several Teams are under the oversight of a Leprosy Control Officer. Over and above a number of Teams there is the Unit Medical Officer in charge, and one with MBBS or M.D. qualifications, specifically trained in leprosy. Because it is a “crime” (due to the stigma ) to diagnose a person as having “leprosy”, when the disease may be, for example, Syphilis, Diabetic Ulcers or Burgei’s Disease, caused by smoking tobacco, it is essential, in a well-functioning Control Programme, to have the diagnosis made by more than one person.
PMW’s are trained in the Differential Diagnosis of leprosy and, within limits, must be able to distinguish between the following leprosy-like conditions that can be confused with early and / or advanced forms of Hansen’s Disease, viz :- Syphilis, Post Kalaazar Dermal Leishmaniasis, Lupus Vulgaris, Psoriasis, Discoid Lupus Erythematosus, Tinia Corporis, Granuloma Annulare, Reaction to Injury, Vitiligo, Tinea Versicolor,Pityriasis Rosea, Scleroderma, Seborrhoeic Dermatitis, Multiple Neurofibromatosis, Multiple Lipomatosis, Hypothyroidism, Diabetic Mellitus Ulcers, Burgei’s Disease, Carpel Tunnel Syndrome, Bell’s Palsy, Allergic Dermatitis, Syphilitic Neuritis, Bernhardt’s Syndrone, Progressive Muscular Atrophy, Syringomyelia (rare), Radiation Necrosis (rare), Toxic Neuritis, Traumatic Neuritis due to physical injury to a nerve, “Cervical Rib”, Vitamin B Deficiency, Congenital Absence of Pain (rare), Over-riding of the Ulnar nerve (rare), Hypertrophic Interstitial Neuritis, Hyperpigmented patches on the faces of children affected by malnutition or worm infestation, Naevus Anaemicus (birth marks) Primary Amyloidosis of Nerves. etc. etc..etc. . In some cases, the PMW cannot fully diagnose, as in the case of the last condition and others which require more complete medical training and laboratory tests such as nerve biopsies.
Where the PMW is unable to make a definite diagnosis, his / her Supervisor may be able to make a confirmation. Where the Supervisor is unable to differentiate, the diagnosis is referred to the Leprosy Control Officer and where the latter needs further confirmation of his / her diagnosis, the final diagnosis is made by the MBBS / M.D leprologist. Naturally, when we are dealing with thousands of patients, it is impossible to provide enough leprologists to do all this by themselves.
Because of the magnitude of the sufferings of those with neglected, untreated Hansen’s Disease, it is essential for us to maintain our fight against this disease in the hope that, eventually, it may be eradicated. Incidently, in the early stages of the disease, no suffering whatsoever is experienced. Leprosy is curable and all its crippling deformities and ulcerations totally preventable.
If you have further interest, please access our
"FORUM ON LEPROSY"
and check out
THE WORLD HEALTH ORGANISATION'S (W.H.O.) LATEST TREATMENT REGIMEN (MDT)
While visiting the W.H.O. be sure to catch up on the latest trends in leprosy's Global Situation - including leprosy in YOUR country - and the most recent world-wide Epidemiological Report on the disease.
If you would like to read of our experiences in India, caring for leprosy sufferers, when, at times, back in the 50's, we had no access even to the simplest of anti-leprosy drugs, please access chapter 10 of our autobiographical book "AN IMPOSSIBLE DREAM" - which is our autobiography of 31 years spent in India and Bangladesh - quite exciting, even if I say it myself !
THE LEPROSY MISSION INTERNATIONAL (T.L.M.), -Please contact for more information.
AMERICAN LEPROSY MISSIONS (A.L.M.)
INTERNATIONAL FEDERATION OF ANTI-LEPROSY ASSOCIATIONS( I.L.E.P.)- which is a federation of about 20 agencies, and of which TLM and ALM are members
ALT.SUPPORT.LEPROSY NEWSGROUP -
W.H.O.'s LATEST RECOMMENDED TREATMENT REGIMEN
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