Dermatological manifestations of Leprosy

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Dermatological manifestations of Leprosy

• Dr (Prof.) H K Kar
• Consultant and Head
• Dept. of Dermatology, STD Leprosy,
• Dr R M L Hospital, New Delhi-110001

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Cardinal signs of Leprosy

• 1. Anaesthetic/hypoaeshetic skin lesion or
  lesions
• 2. Enlarged peripheral nerve\s with impairment of
  sensations in the area supplied
• 3. Acid-fast bacilli in the slit skin smear
  Any one of these signs is sufficient for
  diagnosis of leprosy. Two of them are clinical.
  Therefore clinical skill of the health care
  worker is important for diagnosis of leprosy.

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Clinical spectrum of Leprosy

• LL BL BB BT TT IL Healthy
  contact
• MB Leprosy
• PB Leprosy

Resistance to M. leprae
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Evaluation of Leprosy lesions

• Negative contact (M. leprae_)
• Positive Contact (M. leprae)
• .
• Indeterminate Phase
• PN
  LL
• TT
• Borderline spectrum
• BT BB BL

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1. Indeterminate leprosy

• single or few hypo - pigmented or faintly
  erythematous macules with ill defined to fairly
  well defined margin, slight sensory loss
• 70 heal spontaneously
• 30 progress to any determinate spectrum

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Indeterminate leprosy
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Indeterminate Leprosy
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Pityriasis alba
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2. Pure neuritic leprosy

• Diagnosed by excluding presence of any active or
  previously active skin lesions and history of
  previous treatment
• Asymmetrical one or more nerve thickening with
  sensory\motor deficit
• Lepromin test and nerve biopsy done to find out
  the leprosy spectrum

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Pure neuritic leprosy
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Congenital sensory neuropathy
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Congenital sensory neuropathy with trophic ulcer
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3. Tuberculoid Leprosy

• a. Plaque type
• b. Macular type

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3a.Tuberculoid leprosy (plaque type)

• -Single or 2 or 3
• -Erythematous or coppery
• -Dry surface, hairless
• -Raised well defined edge with sharp outer margin
  and sloping inside tendency of central
  flattening
• -Sensation(touch, temp. pain) absent
• -Feeding nerve to the patch or solitary
  peripheral nerve may be thickened
• -AFB negative
• Lepromin

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Sub polar Tuberculoid leprosy (plaque)
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Tinea faciei
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Granuloma annulare
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Granuloma annulare
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Localized scleroderma
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3b.Tuberculoid leprosy ( macular type)

• Usually single lesion of variable size, may be 2
  or 3
• Erythematous or hypo pigmented
• Well demarcated
• Dry, hairless, insensitive surface
• A thickened nerve in vicinity may be present
• Skin smear negative
• Lepromin test

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Nevus dyschromicus
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Borderline Leprosy

• BT
• BB
• BL Macular type, plaque type, or
  annular type

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4. Borderline tuberculoid leprosy (macular
type)

• Few , distributed asymmetrically
• Macular, or plaque or annular
• Variable size
• Dry surface
• Edge well to partial defined
• Small satellite lesions
• Sensory loss moderate to marked
• Feeding nerve to the lesion may be thickened with
  or without peripheral nerve\s thickening
• AFB nil or scanty(1)
• Lepromin to

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BT (Macular type)
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Borderline tuberculoid leprosy (plaque
type)
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Multiple lesions of Pityriasis
alba
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Polymorphic light eruption
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5. BB Leprosy (macular, plaque, inverted saucer
shaped)

• Several number, bilateral but asymmetrical
  distribution
• Variable size, sloping outer edge central
  punched out area
• Sensation slightly diminished
• Slightly shiny
• Asymmetrical many nerve thickening
• AFB moderate 2to3
• Lepromin negative

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Inverted saucer-shaped lesion of BB
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Healed psoriatic lesions
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6. BL Leprosy ( macular, plaque, infiltration)

• More numerous bilateral, but asymmetrical, more
  shiny, less defined lesions with slight sensory
  loss over them diffuse infilt. at certain areas
• Wide spread nerve damage, asymmetrical
• AFB many (4)
• Lepromin negative

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BL downgrading towards LLs
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From BL Leprosy towards subpolar LL
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Psoriatic patches resembling BL ( Plaque
type)
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7. Lepromatous leprosy (macular stage)

• Bilateral symmetrical innumerable macules in
  early or sub polar phase of LL
• Smooth shiny surface with indistinct margin
  merging imperceptibly with surrounding skin
• Faintly erythematous or copper-colored on dark
  skin
• No loss of sensation
• Lepromin negative
• AFB 4 to 6

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LL (early macular stage)
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PKDL (Macular lesions)
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Tinea Versicolar
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Lepromatous leprosy type (infiltrative, papular,
plaques type, nodular stages)

• Infiltrative stage follows the macular stage
• Diffuse redness of the face, ear lobes, extensor
  aspects of extremities, lower part of the back
  may be the initial presentation
• Initial fine infiltration leads to course
  infiltration
• Course infiltration leads to papules, plaques and
  nodules development due to marked aggregation of
  the infiltrate

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LL (Fine to course infiltration)

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LL (Papules, nodules and plaques)
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PKDL (Nodular lesions)
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PKDL after 6 weeks of treatment with sodium
stiboglunate
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PKDL after treatment
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Variants of lepromatous leprosy

• Histoid leprosy waxy, shiny, firm
  nodules\plaques, which appear over apparently
  normal looking skin, may be asymmetrical
• Lucio leprosy non-nodular occurring in Mexico
  and Central America, diffuse shiny infiltration
  of the skin, loss of body hair, loss of eyebrows
  and eyelashes and wide spread sensory loss.

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Histoid nodules in LL
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Histoid nodules plaques in LL
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Lupus miliaris disseminata facie (LMDF)
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Mycosis fungoides
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Leprosy Reactions

• immunologically mediated episodes of acute or
  subacute inflammation affecting the skin, nerves,
  mucous membrane and\or other sites which
  interrupt the chronic course of leprosy. Unless
  promptly and adequately treated, can result in
  deformity and disability.

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Leprosy Reactions

• Mainly two types
• Type 1 Reaction (T1R) or RR
• occur in BT, BB BL patients.
• Type 2 Reaction (T2R) or ENL occur in BL/LL
  patients.

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Type 1 leprosy reaction
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TTS in Type 1 reaction (RR)
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Type 2 reaction (ENL)
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Type 2 reaction (ENL)
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Type 2 Reaction in LL (ENL
Necroticans)
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ENL necroticans improved 2 weeks after
Thalidomide administration
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Trend in leprosy spectrum over a period of 10
years data from an ULC of Delhi Indeterminate
leprosy
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Trend in leprosy spectrum over a period of 10
years data from an ULC of Delhi TT leprosy
2004
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Trend in leprosy spectrum over a period of 10
years data from an ULC of Delhi BT leprosy
2004
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Trend in leprosy spectrum over a period of 10
years data from an ULC of Delhi BB leprosy
2004
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Trend in leprosy spectrum over a period of 10
years data from an ULC of Delhi BL leprosy
2004
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Trend in leprosy spectrum over a period of 10
years data from an ULC of Delhi LL leprosy
2004
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Trend in leprosy spectrum over a period of 10
years data from an ULC of Delhi PN leprosy
2004
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To summarize

• Clinical acumen essential to diagnose leprosy by
  excluding various other skin and nerve conditions
  mimicking leprosy lesions
• Slit smear examination for diagnosis of early LL
• Skin biopsy in doubtful cases

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Thanks for your kind attention
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Lepromatous leprosy systemic manifestation

• Leprosy bacilli found in lymph nodes, spleen,
  liver, bone marrow, adrenal gland, smooth and
  striated muscles, tooth pulp, testes, oral
  cavity, nose, larynx, and eyes.
• Involvement of testes leads to sterility first,
  then gynaecomastia and impotency

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Nerve examination including functional assessment

• Essential for diagnosis, to evaluate clinical
  spectrum, classification, leprosy reaction
  including neuritis, treatment regimen and
  prognosticating disability
• Palpation of the nerves to detect thickening and
  tenderness
• Sensory testing, motor testing, testing for
  autonomic nerve function

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Causes of Relapse in Leprosy

• Mean incubation period of relapse 5 2 years
• Possible causes of Relapse
• A. Early relapse
• 1. original misclassification
• 2. inadequate chemotherlesion or damage
• If confirmed
• apy (including irregular treatment )
• 3. Insufficient duration
• B. Late relapse
• 4. Drug resistance particularly with past history
  of monotherapy or drugs given sequentially or in
  a combination of two, especially to patients
  with resistance, in effect as monotherapy.
• 5. M. Leprae persistors
  
  (Pattyn SR et al Eur J Epidemiol
  19884231-234)

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Relapse in Leprosy

• New skin lesion
• New nerve lesion or damage
• If confirmed
• 1. MB patients to be given another course of
  same MDT regimen for MB leprosy
• 2. PB cases to be treated with same MDT
  regimen for PB leprosy, if their disease is still
  PB. If diagnosed as MB should be given MDT for MB
  leprosy

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Problems of over diagnosis

• Wrong diagnosis in 0 to 28.6 (9.4) Govt. of
  India, WHO, NIHFW 2004
• Causes
  1. lack of knowledge by HCP to exclude
  dermatological and neurological conditions
  mimicking leprosy, therefore many
  doubtful cases included
  2. no consensus on case
  definition leading to over diagnosis by including
  inactive cases and treated cases as active cases

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Causes of under diagnosis

• Thicken peripheral nerve with sensory deficit
  highly subjective
• Tools used for sensation testing in the field is
  of low to moderate scientific validity
• Lesions on the face, difficult to elicit sensory
  impairment
• Difficult to diagnose clinically the early LL
  cases without slit smear examination and\or skin
  biopsy

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Criteria to diagnose Relapse in PB Leprosy
(strictly clinical)

• Occurrence of definite new dermatoneurological
  lesions without any sign of reaction on the
  lesion
• Extension of old lesion
• New sensitive alterations of the area
• Reactional lesions not responding to oral steroid

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Criteria to diagnose Relapse in MB Leprosy
(both
clinical and bacteriological)

• Occurrence of definite new lesions including
  histoid lesions
• Increase of BI of gt2 or over the previous value
  from any site
• Demonstration of viable M. leprae by mouse
  footpad inoculation
• (G Norman et al Relapse in MB patients treated
  with MDT until smear negativity findings after 20
  years. Int. J. Lepr.2004 72(1)1-7.)

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Diagnosis of relapse

• 1. Clinical gold standard
• 2. Slit skin smear examination
• 3. Histopathological examination
• 4. Mouse foot pad inoculation
• 5. Role of molecular biological techniques to
  confirm relapse

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Congenital sensory neuropathy with cracks, ulcers
and scars
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TTs with RR in a HIV ve patient
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