Leprosy · House

Red Flags

Type 1 (reversal) reaction with new neuritis or motor weakness — emergency prednisolone; risk of permanent disability if untreated^[1]
Type 2 (erythema nodosum leprosum) reaction with severe systemic features (fever, neuritis, iritis, orchitis, glomerulonephritis) — admit; thalidomide or prednisolone^[1]
Eye involvement (lagophthalmos, iritis, corneal anaesthesia) — emergency ophthalmology; risk of blindness^[1]
Suspected dapsone hypersensitivity syndrome (rash, fever, hepatitis, eosinophilia) — stop dapsone, admit; mortality 10%^[1]

First-line treatment

Interventions

WHO multidrug therapy classification^[1]
Paucibacillary: ≤5 lesions and skin smear negative — rifampicin + dapsone × 6 months. Multibacillary: ≥6 lesions or smear positive — rifampicin + dapsone + clofazimine × 12 months. Free fixed-dose blister packs distributed via NLEP
Reaction management^[1]
Type 1 (reversal): prednisolone 30–40 mg PO daily, taper over 12–20 weeks; protect peripheral nerves. Type 2 (ENL): mild — NSAIDs and clofazimine; severe — thalidomide 100–300 mg/day or prednisolone; pregnancy contraindicates thalidomide
Disability prevention and rehabilitation^[1]
Self-care education for hands, feet, and eyes; protective footwear and gloves; daily soaking and oiling; physiotherapy; reconstructive surgery for established deformity
Single-dose rifampicin post-exposure prophylaxis (SDR-PEP)^[1]
All household, neighbourhood, and social contacts of confirmed leprosy patients aged ≥2 years — single dose of weight-adjusted rifampicin reduces incident leprosy by ~57%; component of WHO 2024 update and Indian programme rollout

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Rifampicin^[1]	Rifamycin antibiotic	600 mg PO once monthly supervised (in MDT); 600 mg single dose for SDR-PEP	10–14 years: 450 mg monthly. <10 years: 300 mg monthly. SDR-PEP weight-based per WHO chart	Highly bactericidal first-line; orange staining of body fluids; drug interactions (warfarin, OCs, antiretrovirals); LFT monitoring
Dapsone^[1]	Sulfone antibiotic	100 mg PO daily self-administered	10–14 years: 50 mg daily. <10 years: 25 mg daily	Bacteriostatic; G6PD screening helpful before starting; haemolytic anaemia, methaemoglobinaemia; rare dapsone hypersensitivity syndrome
Clofazimine^[1]	Phenazine antimicrobial	300 mg PO once monthly supervised + 50 mg PO daily self-administered	10–14 years: 150 mg monthly + 50 mg every other day. <10 years: 100 mg monthly + 50 mg twice weekly	Multibacillary regimen; reddish-black skin discolouration (reversible 6–12 months after stopping); mild GI symptoms
Prednisolone (reactions)^[1]	Systemic corticosteroid	30–40 mg PO daily for 4 weeks then taper over 12–20 weeks	1 mg/kg/day taper over 3–4 months	Type 1 reactions and severe Type 2 ENL; bone protection (calcium, vitamin D, bisphosphonate per fracture risk); glucose monitoring; PJP prophylaxis if prolonged
Thalidomide (severe ENL)^[1]	Immunomodulator	100–300 mg PO at night × 1–2 weeks then taper	—	Severe Type 2 ENL not responding to clofazimine; ABSOLUTELY contraindicated in pregnancy — strict pregnancy-prevention programme

Rifampicin^[1]

Rifamycin antibiotic

Adult: 600 mg PO once monthly supervised (in MDT); 600 mg single dose for SDR-PEP
Paediatric: 10–14 years: 450 mg monthly. <10 years: 300 mg monthly. SDR-PEP weight-based per WHO chart

Highly bactericidal first-line; orange staining of body fluids; drug interactions (warfarin, OCs, antiretrovirals); LFT monitoring

Dapsone^[1]

Sulfone antibiotic

Adult: 100 mg PO daily self-administered
Paediatric: 10–14 years: 50 mg daily. <10 years: 25 mg daily

Bacteriostatic; G6PD screening helpful before starting; haemolytic anaemia, methaemoglobinaemia; rare dapsone hypersensitivity syndrome

Clofazimine^[1]

Phenazine antimicrobial

Adult: 300 mg PO once monthly supervised + 50 mg PO daily self-administered
Paediatric: 10–14 years: 150 mg monthly + 50 mg every other day. <10 years: 100 mg monthly + 50 mg twice weekly

Multibacillary regimen; reddish-black skin discolouration (reversible 6–12 months after stopping); mild GI symptoms

Prednisolone (reactions)^[1]

Systemic corticosteroid

Adult: 30–40 mg PO daily for 4 weeks then taper over 12–20 weeks
Paediatric: 1 mg/kg/day taper over 3–4 months

Type 1 reactions and severe Type 2 ENL; bone protection (calcium, vitamin D, bisphosphonate per fracture risk); glucose monitoring; PJP prophylaxis if prolonged

Thalidomide (severe ENL)^[1]

Immunomodulator

Adult: 100–300 mg PO at night × 1–2 weeks then taper
Paediatric: —

Severe Type 2 ENL not responding to clofazimine; ABSOLUTELY contraindicated in pregnancy — strict pregnancy-prevention programme

Safety-net

Take MDT every day until you complete the full course; stopping early causes treatment failure and resistant disease^[1]
Daily self-examination of hands, feet, and eyes; wear protective footwear; treat any cut or burn early — anaesthetic limbs damage easily without warning^[1]
Tell every household and close contact about preventive single-dose rifampicin — it reduces their lifetime risk of leprosy^[1]

Referral criteria

Severe Type 1 or Type 2 reaction with new motor weakness, severe neuritis, or eye involvementDermatology / leprosy unit same-day; admission for IV steroid if severe^[1]
Drug intolerance, treatment failure, or relapseDermatology / leprosy referral centre for resistance testing and second-line^[1]
Established deformity (claw hand, foot drop, lagophthalmos)Plastic surgery / hand surgery / ophthalmology for reconstructive options^[1]
Pregnancy with leprosyJoint dermatology and obstetric clinic; thalidomide absolutely contraindicated^[1]

Clinical summary

Diagnosis, multidrug therapy, reaction management, and contact prophylaxis for paucibacillary and multibacillary leprosy.

References

1.ICMR Consensus on Leprosy Management (2021); WHO Guidelines on the Diagnosis, Treatment and Prevention of Leprosy (2018, with PEP update 2024); NLEP (2024)