Military Dermatology

To classify patients within this tremendous clini-

cal and histological spectrum, several classification
schemes have been proposed. The most popular,
and the one endorsed by WHO, is the Ridley and
Jopling Classification, with minor modifications
(Table 14-1 and Figure 14-4). Histological classifi-
cations, by contrast, are much more expensive (and
are thus impractical for use in third-world coun-
tries and in field situations) and they do not help
further categorize patients except for those in the
reactional states (which are discussed later in this
chapter).28 Exhibits 14-1 through 14-7 and Figures
OK to put on the Web 14-5 through 14-12 are designed to aid in the diag-
nosis of leprosy in its various manifestations.
The polar forms—lepromatous leprosy (LLp) and
tuberculoid leprosy (TTp)—tend to be stable clini-
cally, whereas the borderline forms—borderline
lepromatous (BL), borderline leprosy (BB), and bor-
derline tuberculoid (BT)—tend to be unstable. The

Fig. 14-3. This patient has advanced lepromatous leprosy

with significant cutaneous and ocular disease. Note the
severe lagophthalmos, which has led to an exposure
keratitis, and the severe deformity of the fingers, which
is a consequence of chronic trauma and secondary infection
following anesthetic changes in the distal extremities.

TABLE 14-1
MODIFIED RIDLEY-JOPLING CLASSIFICATION FOR LEPROSY

Characteristics of Lesions
Stage of Disease Number Size Surface Sensation* Hair Growth

Polar lepromatous Very many Small Shiny Not affected Not affected
(LLp)
Subpolar lepromatous Very many Small Shiny Not affected Not affected
(LLs)
Borderline lepromatous Many Variable Slightly shiny Slightly diminished Slightly diminished
(BL)
Borderline borderline Several Variable Dry Slightly to moderately Moderately diminished
(BB) diminished
Borderline tuberculoid Few or 1 Variable Dry Moderately to Moderately diminished
(BT) markedly diminished
Subpolar tuberculoid Usually 1 Variable Very dry Absent Absent
(TTs)
Polar tuberculoid Usually 1 Variable Very dry Absent Absent
(TTp)

* Does not pertain to lesions on the face

† AFB: Acid-fast bacilli

334
 Leprosy

Spontaneous
Healing > 99%

Polar
Tuberculoid
Leprosy = TTp

75%
Borderline
Tuberculoid
Leprosy = BT

Exposure to Borderline
Leprosy Borderline
Bacillus Leprosy = BB
Subclinical Indeterminate 25%
Infection 0.5% Leprosy = IL
Borderline
Lepromatous
Leprosy = BL

Polar
Lepromatous
Leprosy = LLp
Fig. 14-4. The pathogenesis of leprosy. Exposure usually
results in spontaneous healing. Subclinical infection
progresses to indeterminate leprosy, which spontane-
Lucio's Diffuse
ously remits in 75% of patients; however, in 25% of
Lepromatous
patients, the disease progresses to one of the more seri- Leprosy = LLp
ous forms of leprosy.

AFB Found Bacterial Index

Contain AFB † in Nasal Secretions (Ridley) Lepromin Test Comment

Very many (plus globi) Very many (plus globi) 5–6 Negative Polar lepromatous leprosy

Very many (plus globi) Very many (plus globi) 5–6 Negative Downgraded to LL from BL due
to lack of therapy
Many Usually nil 4–5 Negative Unstable immunity

Moderate Nil 3–4 Negative Unstable immunity

Nil or scanty Nil 0–2 Weakly positive Unstable immunity

(+ or ++)
Nil Nil 0–1 Strongly positive Upgraded to TT from BT
(+++) due to treatment or nutrition
Nil Nil 0–1 Strongly positive Polar tuberculoid leprosy
(+++)

335
Military Dermatology

600 mg in adults

Rifampin
supervised, (450 mg < 35 kg)
1 dose/mo • 6

Paucibacillary 10 mg/kg in
Disease children

100 mg in adults
Plus Dapsone,
unsupervised OK,
daily for 6 mo
1–2 mg/kg in
children

600 mg in adults
Rifampin,
Treatment
supervised,
Of
1 dose/mo for
Leprosy
≥ 24 mo
10 mg/kg in
children

100 mg in adults

Plus Dapsone,
unsupervised OK,
daily for ≥ 24 mo
Multibacillary 1–2 mg/kg in
Disease children

Supervised,
300 mg in adults,
1 dose/mo for
≥ 24 mo

Plus
unsupervised,
Plus Clofazimine
50 mg daily for
≥ 24 mo

Children,
1–2 mg/kg for
both monthly and
daily doses

Fig. 14-13. World Health Organization guidelines for the treatment of uncomplicated leprosy. Data source: WHO
Expert Committee on Leprosy. World Health Organization Technical Report Series 768. 6th report. Geneva, Switzerland:
World Health Organization; 1988.

344
 Leprosy

Polar
Tuberculoid
Leprosy = TTp

Subpolar
Tuberculoid
Leprosy = TTs

Borderline
Tuberculoid
Leprosy = BT

Borderline
Borderline
Leprosy = BB
Downgrading

Indeterminate
Leprosy = IL
Reversal

Borderline
Lepromatous
Leprosy = BL

Subpolar Erythema
Lepromatous Nodosum
Leprosy = LLs Leprosum (rare)

Polar Erythema
Lepromatous Nodosum
Leprosy = LLp Leprosum

Lucio’s Diffuse Erythema

Lepromatous Lucio’s Nodosum
Leprosy = LLp Phenomenon Leprosum

Fig. 14-15. The possible reactional states in leprosy: reversal reaction, also called Type 1 (red); erythema nodosum
leprosum, also called Type 2 (blue); downgrading reaction (green); and Lucio’s phenomenon (yellow). Note that
erythema nodosum leprosum can occur via three pathways.

347
 Leprosy

Prednisone
40–80 mg/d
with taper over
3–6 mo

Type 1: Clofazimine may

Reversal be steroid-
Reaction sparing in
chronic reactions

Thalidomide
not useful

Analgesics (ie,
aspirin)

Mild reactions

Chloroquin,
Antimonials
(Stibophen)

Prednisone
40–80 mg/d
With neuritis
tapering slowly
over months
Acute reactions
Prednisone
Without neuritis 40–80 mg/d,
quick taper
Type 2: possible
Treatment of Erythema
Reactional Nodosum
States Leprosum Drug of choice
in relapses and
chronic cases
Thalidomide
100 mg qid,
taper over
few weeks
Contraindicated
in pregnant
females
Chronic
reactions and
relapses
Clofazimine 100 Slow onset, may
mg tid 4–6 wk, be used in
bid for months pregnancy

May be used in
Prednisone pregnancy

Downgrading Treat for

Reactions multibacillary
disease

Prednisone

Lucio’s
Phenomenon
Dapsone
plus
Rifampin

Fig. 14-17. Treatment algorithm for reactional states in leprosy.

349