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.