A 30-Year-Old Man With a 2-Year History of Rash

Adam R. Taintor, MD

Disclosures

May 18, 2009

Treatment

A correct classification of a patient's leprosy subtype and an understanding of the various possible reactions to treatment are necessary in guiding the patient's pharmacologic treatment to avoid permanent nerve and organ damage.

The National Hansen's Disease Foundation[11] protocol for treating paucibacillary disease includes the use of dapsone 100 mg daily plus rifampin 600 mg daily for 1 year. Treatment for multibacillary disease includes the paucibacillary disease protocol of dapsone plus rifampin, plus an additional agent, which may be clofazimine, minocycline, or a fluoroquinolone. Clofazimine is preferred. Of note, rifampin is given at a much lower dose until a clinical response to the other 2 drugs is seen. Our patient was started on rifampin 300 mg once every month. Multibacillary disease is treated for 2 years. Patients are no longer contagious after 1 week of treatment.

Clofazimine, which must be obtained with an institutional review board through the National Hansen's Disease Program, assists in increasing the clearance of bacilli and can reduce the risk of some leprosy reactions. However, it can cause pigmentary changes, which is one of the main reasons patients do not tolerate the drug. The pigmentary changes usually resolve after finishing treatment.

In the case of our patient, he is tolerating his medications 6 months into treatment without any complaint of fever, malaise, or nerve pain. He began regaining sensation in his anesthetic lesions 3 months into treatment. Initially, the lesions became pigmented orange secondary to the clofazimine, but this change decreased with time. The patient's only complaint during treatment was of xerotic dermatitis, more likely to be associated with cold, long Milwaukee winters than anything else. It resolved with frequent emolliation and desoximetasone twice daily for 2 weeks. The patient has had no additional lesions or occurrence of any reactional states.

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