CME Article

Newer Management Options in Leprosy

P Narasimha Rao, Suman Jain1
From the Department of Dermatology, Bhaskar Medical College, RR District, Andhra Pradesh, 1Nireekshana-ACET, Narayanaguda, Hyderabad, India

Abstract
Newer management options are needed for leprosy control even at present, as it is predicted that new cases of leprosy will continue to
appear for many more years in future. This article detail newer methods of clinical grading of peripheral nerve involvement (thickening,
tenderness and nerve pain which are subjective in nature) and the advances made in the use of Ultrasonography and Colour Doppler
as an objective imaging tool for nerves in leprosy. It also briefly discusses the newer drugs and alternative regimens as therapeutic
management options which hold promise for leprosy in future.

Key Words: Clinical grading of nerve involvement, leprosy-new management options, newer drugs and regimens, ultrasonography and
colour doppler imaging of nerves

Introduction leprosy with unravelling of M. leprae genome in the year

Leprosy is one of the oldest diseases known to the mankind
and M. leprae was one of the first bacillus to be discovered
and associated with a disease. However, advances in the
management of this disease has been rather slow, compared to
other bacillary diseases, due to the peculiarity of this bacillus
(indolent nature, inability to grow in artificial media etc.)
and the disease (long incubation period, disease spectrum
dependent on host immunity etc.). Despite these short
comings, great strides were made in the effective control and
reaching the elimination target of leprosy in most countries of
the world including India, chiefly due to the introduction of
Multi Drug Therapy (MDT) in 1982 in its management.
While the numbers of leprosy patients decreased and
elimination targets achieved worldwide, it should be noted
that leprosy continues to occur in most parts of erstwhile
endemic countries in good numbers. Unfortunately, the
distinction between eradication and elimination is widely
misunderstood[1] and largely as a consequence, research for
newer options in leprosy has reduced considerably. There is
a need to re-focus on improving the efforts for continuing
education and training of existing personnel and in addition,
strive to attract young minds and scientists to work for leprosy.
Newer options in leprosy
Search for improving existing management options is an
ongoing process in any field and leprosy is no exception.
Finding newer clinical and therapeutic options would be
welcome as they benefit patients straight away while adding
impetus to the leprosy programme, which seems to have
reached a point of stagnation after elimination target was
achieved by India in 2005 and vertical programme merged
with general medical services.
Notwithstanding the slowing of research, significant
advances were made in the last decade in understanding
2000 and advances made in the cellular and molecular
basis for bacillary and host responses. We know now, based
on its genomic configuration, the reason for the dormancy
of M. leprae and it reluctance to initiate antigenic response
in the host. The development of practical and quick DNA
sequencing methods to detect drug resistance has helped
greatly in establishing a sentinel surveillance network for
drug resistance in leprosy.[2] DNA sequencing technology
for M. leprae is in use for testing for drug resistance of
common anti leprosy drugs such as dapsone, rifampicin
and can also be applied to newer drugs such as ofloxacin
as well. Compared to advances made in the cellular and
molecular biology, conceiving applicable newer clinical
management options seem to lag behind in the last decade.
We discuss below some of the recently introduced clinically
applicable techniques and imaging options to define nerve
involvement in leprosy, apart from newer drug regimens
and alternatives to the existing MDT.
Advances in grading of nerve involvement in
leprosy
But for nerve involvement, leprosy would have been a
very simple disease as most complications and ill effects
of leprosy are the direct results of nerve damage. In a
study investigating the pathogenesis of neuropathy in North
India, 94% of patients had nerve enlargement as the most
common sign of leprosy.[3] In leprosy clinics, the nerve
involvement in leprosy is assessed mostly by palpation
of nerves although laboratory methods are also in use in
few tertiary referral centres. Detailed below are clinical
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Address for correspondence: Dr. P Narasimha Rao, B-48, Income Tax DOI: 10.4103/0019-5154.105274
Colony, Mehdipatnam, Hyderabad - 500 028, India. E-mail: dermarao@
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Indian Journal of Dermatology 2013; 58(1) 6

 Rao, et al.: Newer management options in leprosy
grading of peripheral nerve involvement and the use of
ultrasonography as an imaging tool for nerves in leprosy.
Clinical grading of nerve thickness, tenderness
and nerve pain
Palpation of peripheral nerves to assess their thickness
and tenderness is an integral part of clinical examination
in leprosy. Confirmation of nerve thickening by palpation
is important as it is one of the clinical criteria for the
diagnosis of leprosy in a patient. This is performed mainly
at predetermined sites of the body along the course of the
nerves commonly involved. Although terms such as mild,
moderate and severe are used in rating these parameters
for extent of involvement by various workers,[4] systematic
method of grading of nerve thickening, tenderness and pain
is not in practice.
Need for systematic grading of nerve thickening,
tenderness and nerve pain
Nerve involvement in leprosy is a chronic event and once
it occurs, persists for months to years. Hence, changes in
their involvement during phases of leprosy reactions need
to be followed up regularly and judiciously to prevent
and limit the possible nerve damage and nerve function
impairment (NFI). In this context, the grading of nerve
thickening, tenderness and nerve pain are required for the
systematic recording of these important clinical finding in
the medical records at the initial and every follow-up visit
for changes, to assess the effect of treatment instituted on
them and the progress of the disease. Systematic grading
of nerve involvement is also needed for communication of
these observations between workers.
A standardized clinical grading of thickness, tenderness and
nerve pain was not attempted till recently. One such grading
of nerve thickness, tenderness and pain was detailed/
proposed in a leprosy website in the year 2008.[5] Given
below is the modified version of clinical grading of nerve
thickening, nerve tenderness and nerve pain as practiced at
Blue Peter Research Centre (BPRC), in Hyderabad.[6]
Grading of nerve thickening
A four-grade scale (0 to 3) is used to grade nerve thickening
[Table 1]. The nerves are palpated at their most superficial
locations and sites based on standard clinical methods.
Each nerve should be palpated for at least 5 cm of its
length wherever possible to detect beading or nodularity.
Grading of nerve tenderness
A four-grade scale (0 to 3) is used to grade tenderness
[Table 2]. Nerve tenderness is elicited by applying mild to
moderate pressure on the nerve during palpation. As this is
a highly subjective assessment, while palpating the nerve,
look for the patients response (wincing, expression of
distress on face or pulling away of limb) to evaluate the
grade of tenderness. Repeated palpation of tender nerves
should be avoided.
7 Indian Journal of Dermatology 2013; 58(1)
Table 1: Clinical grading of nerve thickness
Grade Degree Description
0 Not thickened Nerve not thickened and feels normal*
1 Mild thickening Thickened compared to contra lateral
nerve
2 Moderate Thickening is rope like
3 Severe Nerve thickened and also nodular or
beaded
*Normal nerve feels soft to firm, flattish and slightly compressible
Table 2: Clinical grading of nerve tenderness
Grade Degree Description
0 None Says palpation is not painful even when
asked about it
1 Mild Says palpation is painful only when asked
about it
2 Moderate Indicates palpation is painful by wincing
during palpation or says so
3 Severe On palpation, tries to withdraw the limb
or is clearly distressed by any pressure
on the nerve
Grading of neuropathic pain
Neuropathic pain also known as nerve pain (NP) is also
defined as pain initiated or caused by a primary lesion or
dysfunction in the peripheral or central nervous system.[7]
According to the Special Interest Group on Neuropathic
Pain (NeuPSIG), the definition of the Neuropathic pain
is,[8] pain arising as a direct consequence of a lesion or
disease affecting the somatosensory system.
Since leprosy is known to cause severe sensory loss
leading to hypo/anesthesia, it is often wrongly assumed
by some that NP is uncommon in leprosy. However, NP
as a symptom can occur in leprosy before, during and
after treatment. During active disease, patients who usually
complain of NP are patients of pure neuritic leprosy
and tuberculoid patients with type 1 reactions, although
lepromatous patients with recurrent severe type 2 reactions
can have bouts of intense nerve pain involving multiple
nerve trunks. In patients released from treatment NP
occurs due to continued damage to the peripheral nerves,
probably due to the persistent low grade inflammation and
its sequelae. It could last for months to years.
The underlying pathological mechanisms put forward
for NP include, excessive firing of pain mediating nerve
cells that are insufficiently controlled by segmental and
non-segmental inhibitory circuits and small fibre sensory
neuropathy (SFSN) which predominantly affects small
nerve fibres and its functions.[9] NP includes a wide
spectrum of symptoms such as paraesthesia, dysaesthesia,
hyperesthesia and allodynia along the nerve and in its area
of distribution. The occurrence of paraesthesia could be
in as high as in 24 % of the leprosy patients as observed
in an Indian study.[3] Patient usually describes NP as
 Rao, et al.: Newer management options in leprosy
shooting dragging pulling or electric shock like,
and also as Jhum Jhum in nature,[10] which can force the
patient to keep the limb in a position of rest. The most
typical symptoms of chronic neuropathic pain in treated
leprosy patients are continuous burning pain, dysesthesia,
paresthesia, paroxysmal pain attacks.
Please note that nerve tenderness is an elicitable sign,
while nerve pain is a symptom complained by the patient.
The grading of nerve pain is based on the severity as
described by the patient, hence it does not need palpation
of the nerve. Some workers have come out with a three
page questionnaire for validation of neuropathic pain[11] that
enquires and grades various symptoms of neuropathic pain
which includes: Burning pain, squeezing pain, pressure
like pain, electric shock like pain, stabbing pain, apart
from dysathesia and paraesthesia. It scores each symptom
separately and grades neuropathy based on the total score.
A much simpler four-grade scale (0 to 3) was proposed for
grading of severity of nerve pain[6] based on the severity of
the symptom/s (not on the type of symptom) which can be
applied for each involved nerve in leprosy [Table 3]. Please
note that ideally, nerve pain should be enquired and graded
before the assessment of nerve thickening and tenderness
in a leprosy patient, as palpation of nerve may modify/
influence nerve pain severity grading if done later.
Relevance of clinical grading of nerve tenderness and NP
to therapy: Grade of nerve thickening once recorded is
usually not prone to changes over short intervals of days to
weeks. However, grades of nerve tenderness and pain can
show dramatic changes with or without treatment over short
periods of time. When nerve tenderness and neuropathic
pain is > grade 2; it usually requires immediate institution
of corticosteroid therapy along with other measures to
prevent further nerve function impairment (NFI).
How to record nerve thickness, tenderness and neuropathic
pain: Nerve thickness, nerve tenderness and neuropathic
pain can be designated as Th, T and NP respectively and
the observations recorded in the case sheet. For example,
for left ulnar nerve involvement of grade 2 thickening and
tenderness and grade 1 nerve pain can be recorded as: Left
Table 3: Grading of severity neuropathic pain based on
symptoms
Grade Degree Description
0 None Does not complain of nerve pain; says no
nerve pain even when asked about it
1 Mild Complains of nerve pain even when not asked
about it
2 Moderate Complains of severe nerve pain and points to the
areas of its radiation. The pain does not interfere
with sleep. It is aggravated by repeated use of
the limb such as manual labour, tailoring etc.
3 Severe Says pain is severe, and that it interferes with
sleep; The patient keeps. The limb in a position
of rest and avoids/restricts its movement
Indian Journal of Dermatology 2013; 58(1)
Un: Th2, T2, NP1. Periodic changes can also be noted
similarly in the follow-up sheets. Such detailed recordings
in patients follow-up would especially be useful in clinical,
drug and research studies.
Imaging of nerves in leprosy
The clinical method of assessing nerve damage is principally
by palpation of nerve complemented by tools to test the
integrity of nerve function by testing for motor, sensory and
autonomic integrity by voluntary muscle testing (VMT),
testing for sensation by graded Semmes Weinstein (SW)
mono filaments and sweat test respectively. Other tests
which could be performed are nerve conduction studies by
ENMG and imaging of nerves by Ultrasonography (USG)
and Magnetic resonance imaging (MRI) which require
specialized equipment and skilled technicians.
While clinical grading of nerves is subjective, recent
advances in imaging of peripheral nerves have actually
helped to observe structural changes in the nerves
objectively. Imaging with the help of USG and MRI
is being undertaken and performed worldwide for the
identification of structural changes of peripheral nerve
trunks over last two decades. Although MRI has shown to
depict soft tissues with excellent resolution, it is expensive
and time-consuming and may not always be as readily
available compared with USG. Moreover, it is difficult to
follow the peripheral nerves along its superficial course
for identification of pathology with MRI as can be done
easily with USG. The use of USG to reveal normal
peripheral nerves and peripheral nerve tumors has been
reported extensively in the radiology literature. Because
of new technical developments, the resolution of USG has
improved considerably and is sometimes even better than
standard MRI.[12] Peripheral nerves have a typical USG
pattern that correlates with histologic structure and USG
with frequencies higher than 10 MHz are being used to
support conventional USG in the depiction of superficial
structures such as peripheral nerves and tendons.[13] Imaging
of peripheral nerves can be done with reasonable precision
with USG with broadband frequency of 10-14 MHz; CD
frequency of 6-13 MHz and linear array transducer.
Normal peripheral nerves of extremities have been descried
as markedly echogenic tubular structures with parallel
linear internal echoes on longitudinal sonograms [Figure 1]
with round to oval cross section on transverse scans with
occasional internal punctuate echoes.[14,15] Sonographic
imaging allows complete analysis of median, ulnar,
posterior tibial nerve and studies have shown that the site
of maximum involvement was limited to 6-10 cm above the
flexor retinaculum for median nerves, 8-12 cm proximal to
the cubital groove for ulnar nerves, and 4-10 cm proximal
to the medial malleolus for posterior tibial nerve.[16]
Not only can the above mentioned nerves, any peripheral
nerve of reasonable thickness can be imaged by USG.
Results of high resolution USG imaging on ulnar, radial,
8
 Rao, et al.: Newer management options in leprosy
Figure 1: Ultrasonography image of the longitudinal scan of a healthy nerve
median, femoral, common peroneal, posterior tibial, sciatic
nerves and on brachial plexus in healthy subjects and various
disease states were already reported.[12,17] Healthy nerves
show in transverse section a honeycomb like appearance
made of hypo echoic fascicles surrounded by hyper echoic
epineurium [Figure 2]. Nerve thickness may be quantified on
longitudinal scan by measuring the antero-posterior diameter
or on transverse scan by measuring the diameters in the scan
or calculating the cross sectional area (CSA). The modern
ultra sound machines are usually equipped with software to
easily perform these measurements including CSA, accurate
to the tenth of a millimetre. Studies have shown that USG
was a very precise method to assess the dimensions of
peripheral nerve trunks and ultrasound measurements were
reliable. In addition, high resolution USG can support clinical
and electro-physiologic testing for detection of a variety of
nerve abnormalities, including entrapment neuropathies,
trauma, infectious disorders and tumors.[18]
Most modern sonographic machines use pulsed colour
doppler to assess whether structures, usually blood, are
moving towards or away from the probe and its relative
velocity. Color Doppler (CD) imaging of each nerve can
be performed to look for absence or presence of blood
flow signals in the perineural plexus and interfascicular
vessels of nerve trunks. In health, neither the fascicles
nor the epineurium show CD signals indicating normal
(hypo) vascularity of nerve trunks. Based on identifying
blood flow signals in these nerve trunks each nerve can be
characterized as either normal or hypervascular. CD settings
can be chosen to optimize identification of weak signals
from vessels with slow velocity. To increase vascular
depiction, the power mode for CD can also be used.
The increased blood flow signals seen in CD in thickened
and tender peripheral nerves of leprosy supports the theory
that they reflect the edematous and hyperemic changes
secondary to the inflammation leading to alteration of an
effective blood-nerve barrier during reversal reactions,[16]
while being independent of the extent of destruction of
nerve fascicles. Nerves of patients with leprosy reactions
9 Indian Journal of Dermatology 2013; 58(1)
Figure 2: Ultrasonography image of transverse scan of a healthy nerve
showing honeycomb pattern
have shown increased blood flow signals in CD in the endo/
perineurium, indicative of increased vascularity, giving a
clue to the diagnosis of persistent reaction in them.[19] As
neuritis in leprosy reactions varies in intensity, the detection
of blood flow signals in those nerves with greater nerve
cross sectional area and tenderness, points to its usefulness
as a tool in assessing the severity of the neuritis.
Significant correlation was observed between clinical
parameters of grade of thickening, sensory loss and muscle
weakness and USG abnormalities of nerve echotexture,
endoneural flow and CSA of nerves.[19] In leprosy, as
important peripheral nerves are involved at selective sites
of predilection at their most superficial locations along
their course, routine USG scanning of these nerves in
patients of leprosy provides an useful information on
their state and extent of involvement. Follow-up USG
imaging of nerves helps to know the changes in the CSA
and structural integrity which could be correlated directly
to treatment efficacy and clinical improvement. Moreover,
such a non-invasive imaging provides documentable proof
of nerve pathology which would be a welcome addition
to the existing tests for detection and follow-up of nerve
function impairment in these patients.
Advantages of imaging over clinical grading of nerves
The thickening of nerves appreciated on clinical
examination is subjective and comparative in relation to
the contralateral nerve. Moreover, confirming enlarged
nerves can be often difficult in nerves such as median
nerve because of their location, which can be overcome by
USG imaging. USG is a very precise assessment method,
while there is considerable inter-observer variability in
assessing the presence of enlarged nerves by palpation.[20] In
comparison, inter-observer agreement between sonographic
measurements is excellent.[21] Besides enlargement, structural
abnormalities such as integrity of fascicular structure, type
of enlargement, edema and state of neural vascularity of
nerves in leprosy patients can be studied by USG.
Newer drugs in leprosy therapy
The WHO recommended MDT regimens have been shown
to be robust i.e. even if taken irregularly, they have benefited
 Rao, et al.: Newer management options in leprosy
patients.[22] As a consequence, MDT for leprosy which was
introduced in 1982 has changed little from its inception in
its basic structure till date. The same three drugs (Dapsone,
Clofazimine and Rifampicin) in the same dosages and
schedules are still in use. Only significant change has been
the reduction in the treatment duration of MB leprosy from
24 months to 12 months in 1998. No new drugs were
introduced in to the programme, although ofloxacin and
minocycline were introduced as a part of ROM (Rifampicin,
Ofloxacin and Minocycline) therapy in 1998 for single lesions
leprosy, only to be withdrawn quietly over next 5 years.[23]
Need for newer drugs and regimens in leprosy
Leprosy is a chronic infectious disease that has a limited
number of drugs available for treatment; therefore, drug
resistance is likely to pose a serious impediment to its
control. The key decisive factor in determining the duration
of chemotherapy is the sterilizing activity of treatment
measured by the relapse rate after completion of treatment.
The emergence of drug resistance is a cause for concern
in this regard and is a threat to any control programme for
infectious diseases. The lack of prioritization in research
and also of resources, and the absence of information on
the magnitude of drug resistance, cannot be considered
as evidence that drug resistance does not exist in leprosy
treatment.[24] It is generally believed that a combination of >2
drugs, with different mechanisms of action, taken regularly
for a sufficient period, will prevent the emergence of drug
resistance. The development of practical and quick DNA
sequencing methods to detect drug resistance has helped
greatly in establishing a sentinel surveillance network for
drug resistance in leprosy. Sentinel surveillance to monitor
the level of drug resistance in relapse cases has been setup
by WHO in Brazil, China, Colombia, India, Myanmar,
Philippines and Viet Nam.[2] At present, drug resistance to
dapsone, rifampicin and the quinolones is being identified
by looking at mutations in the binding sites of these
drugs in large number of samples by molecular biological
methods, not on the mouse footpad cultures anymore,
which is a time-consuming and tedious method. Resistance
to rifampicin and dapsone is reported. Clofazimine and
minocycline resistance has not yet been reported.
Development of rifampicin resistance by M. leprae is
considered a very serious threat to the efficacy of existing
MDT programme. Patients suspected to be rifampicin
resistant are also expected to be resistant dapsone. Hence,
the proposed new MDT regimens could be of two types:
One, to simplify treatment and facilitate supervision of multi
drug administration for rifampicin-susceptible patients; and
the other to treat patients with rifampicin-resistant leprosy or
those who cannot tolerate rifampicin. In the year 1998 WHO
technical advisory committee[25] recommended the following
regimen for adults with suspected rifampicin resistance:
1. Daily administration of 50 mg of Clofazimine, together
with 400 mg ofloxacin and 100 mg of minocycline for
Indian Journal of Dermatology 2013; 58(1)
6 months., followed by
2. Daily administration of 50 mg Clofazimine, together
with 100 mg of minocycline or 400 mg of ofloxacin,
for at least an additional 18 months.
In the last two decades, new drugs with good efficacy against
M. leprae have been identified which can be incorporated
in multidrug regimens for leprosy [Table 4]. With the
availability of these newer drugs, alternate regimens are
being suggested for MB leprosy[25] which however, are still at
a proposal stage. One of the very promising newer drugs[26]
has been moxifloxacin, a broad-spectrum fluoroquinolone
which was found to be the most active and more bactericidal
than ofloxacin against M. leprae in mouse footpads. The
bactericidal activity of moxifloxacin was identical to that of a
single dose of rifampicin. Rifapentin, a rifamycin derivative,
is another drug which has pharmacokinetic properties far
more favorable than rifampicin, with significantly higher
peak serum concentrations and a much longer serum half-life
and was observed to be more effective than a single dose of
rifampicin or the combinatinon of ROM in killing M. leprae
in mouse footpad.[23]
Newer drug regimens suggested for leprosy in 2009 by the
WHO Report of the Global Programme Managers Meeting
on Leprosy Control Strategy is as follows:[27] For rifampicin
susceptible MB patients a fully supervised monthly regimen
could include: Rifapentin 900 mg (or rifampicin 600 mg),
moxifloxacin 400 mg, and clarithromycin 1000 mg (or
minocycline 200 mg) for 12 months. For rifampicin-resistant
patients, the intensive phase could include moxifloxacin
400 mg, clofazimine 50 mg, clarithromycin 500 mg, and
minocycline 100 mg daily supervised for six months. The
continuation phase could comprise moxifloxacin 400 mg,
clarithromycin 1000 mg, and minocycline 200 mg once
monthly, supervised for an additional 18 months.
Conclusion
Are newer management options needed for leprosy control
at present? The answer is emphatic yes, the reason being;
despite the enormous reduction in the number of patients
registered for treatment, it is predicted that new cases
of leprosy will continue to appear for many more years.
Table 4: Newer drug options in leprosy (modified from
WHO Report of the global programme managers
meeting on leprosy control strategy. New Delhi, India,
2009 SEA-GLP-2009.6)
Drug Bactericidal Bactericidal Cost
activity in humans activity in mice
Ofloxacin ++ ++ Moderate
Moxifloxacin +++ +++ High
Clarithromycin ++ ++ Moderate
Minocycline ++ ++ Moderate
Rifapentine Not done +++ High
Diarylquinoline Not done +++ Not available
Linezolid Not done + High
10
 Rao, et al.: Newer management options in leprosy
There is no evidence that the global initiative has led to the
disappearance (local eradication) of infection or disease
from any population, and leprosy continues to appear
throughout Africa, Asia and Latin America.[1] Therefore,
health services must sustain the provision of quality
services at all levels in the foreseeable future. The WHO
Enhanced Global Strategy for years 2011-2015[28] has been
formulated as a natural extension of its earlier strategies
to help to sustain the gains made so far and further reduce
the disease burden in all endemic countries. The strategy
envisages reinforcing leprosy control agenda by investing in
targeted research to find more powerful anti-leprosy drugs;
to find new therapies for the prevention and management
of neuritis and reactions and innovative interventions to
prevent and limit disabilities due to leprosy. It is important
that the current declining trend in the burden of leprosy be
maintained in India and other countries where the disease is
endemic. To maintain this momentum, new cases should be
detected in a timely fashion, properly diagnosed and treated.
Prevention and treatment of complications and nerve
function impairment are to be sustained and improved by
discovering newer management options for leprosy. Finally,
community awareness of the disease needs to be increased
so that people present for diagnosis at an early stage.
Acknowledgements
We acknowledge the help of Dr. TLN Praveen, Abhishek
Institute of Imageology, Secunderabad, Andhra Pradesh, India for
providing the USG images of peripheral nerves.
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How to cite this article: Rao PN, Jain S. Newer management options
in leprosy. Indian J Dermatol 2013;58:6-11.
Received: January, 2011. Accepted: February, 2011.
Source of support: Nil, Conflict of Interest: Nil.
Indian Journal of Dermatology 2013; 58(1)
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