A NEW

ATLAS OF LEPROSY
A pictorial manual to assist frontline health workers and volunteers in the
detection, diagnosis and treatment of clinical leprosy

A. Colin McDougall
Yo Yuasa

SASAKAWA MEMORIAL HEALTH FOUNDATION

Tokyo, Japan
2002
 Contents
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Flowchart for diagnosis and classification of leprosy . . . . . . . . . . . . . . . . . . . . . .2

Multidrug Therapy (MDT) as advised by the World Health Organisation . . . . . .3

Illustrations of MDT for multibacillary (MB) and paucibacillary (PB)

drugs in blister calendar packs (BCPs) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

‘Before and After MDT’ — results of treatment . . . . . . . . . . . . . . . . . . . . . . . . .8

Leprosy lesions 10

1. Paucibacillary leprosy (PB) leprosy; 1–5 skin lesions . . . . . . . . . . . . . . . . . .11

2. Multibacillary (MB) leprosy; 6 or more skin lesions . . . . . . . . . . . . . . . . . . . .24

Neural leprosy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Reactions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Type 1 reactions (reversal, upgrading) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Type 2 reactions (lepromatous, ENL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Disability–deformity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

Non-leprosy conditions of the skin 46

(differential diagnosis)

(a) Simple commonly occurring conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

(b) Less commonly occurring conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

References and Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

Publishing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Inside Back Cover

Leprosy is curable
with Multidrug Therapy
which also prevents
disability and deformity
Let us join hands to work towards
A WORLD WITHOUT LEPROSY
 1
Yo Yuasa
Foreword Executive & Medical Director
Sasakawa Memorial Health Foundation, Tokyo, Japan

The original Atlas of Leprosy was developed in 1981 in close collaboration with Dr R. S. Guinto and
his colleagues of the Leonard Wood Memorial Laboratory, Cebu, Philippines. The initial 230 copies, in a
larger prototype format, were practically handmade, but the response was so favourable that we decided
to produce the Atlas in a regular printed format in 1983. Our intention was to supply a collection of high
quality pictures of leprosy, both clinical and histopathological, primarily for doctors and senior
paramedical workers to aid their training activities, in addition to its use as reference material. As a
teaching aid we also produced a colour slide version. Little did we expect, at the outset, the subsequent
overwhelming and continuous demand, even up to today, resulting in 38,000 English copies, as well as
23,000 copies in six other languages – a ‘best seller’ on leprosy, though practically all are given out gratis.
The global leprosy scene was changing quite rapidly, almost concurrently with the publication of the
original Atlas in 1981. Starting with the historic Chemotherapy Study Group Meeting in October that
year, multidrug therapy (MDT) has been primarily instrumental in this remarkable change. The 1991
World Health Assembly resolution on the ‘Elimination of leprosy, as a public health problem’ further
accelerated that process. The 122 leprosy-endemic countries of the mid 80’s are likely to come down to
around 15 by the end of this year. WHO is now embarking on a ‘Final Push’, so that by the end of 2005,
there should be no more leprosy-endemic countries left in the world, meaning that no country will have
more than one case in 10,000 of the population. That will indeed be a great accomplishment.
However, for those deeply involved in leprosy work, such an achievement only signifies reaching an
interim goal or a milestone, however significant it may be. Our final goal is ‘A World Without Leprosy’,
in which every single new case (and new cases will undoubtedly keep arising) has been diagnosed and
put on to MDT as quickly as possible. With reduced caseload, such basic leprosy control activities are
likely to be handled, not by specialised vertical services, but general health services personnel.
This new Atlas, as the subtitle on the cover indicates, aims to assist frontline health workers, both
the peripheral general health workers as well as village health volunteers, to carry out case finding as
effectively as possible. Unlike the original Atlas, in which the pictures were all from the Philippines with
relatively light coloured skin, this new Atlas has pictures mostly from India and Bangladesh, an area
which will continue to have nearly 80% of the global caseload. Our intention is to produce enough
copies of the Atlas to equip every peripheral health facility of that immense area with one copy,
probably requiring 200,000 copies or more.
Dr Colin McDougall, an eminent leprosy specialist, has kindly accepted the responsibility of producing
this volume. My name appears on the cover, primarily to take a full responsibility in choosing pictures
or making statements, on which he had some doubts with regard to appropriateness in this volume.
The original Atlas was intended to strengthen leprosy control activities, at a time when no end point
of our efforts was in sight. This new Atlas is meant to serve until the end of our efforts. Ambitious?
Yes, but not, I hope, altogether unrealistic.
2
Flowchart for Diagnosis and Classification
(Grouping for Multidrug Therapy)
Look for skin lesions
compatible with SKIN LESION WITH
leprosy and test for SENSORY LOSS
sensory loss

Diagnose LEPROSY

When skin-smears
are not available UP TO 5 SKIN MORE THAN 5 SKIN
or not LESIONS LESIONS
dependable

Classify PB LEPROSY MB LEPROSY

(Clinically)

When skin-smears
are available SMEAR NEGATIVE SMEAR POSITIVE*
and dependable

Classify PB LEPROSY MB LEPROSY

(Bacteriologically)

*Any patient showing a positive skin smear, irrespective of the clinical classification, should
be treated with the multibacillary (MB) regimen. However, this depends on the availability
of reliable laboratory facilities. Furthermore, the increasing prevalence of the HIV and
hepatitis B infection in many leprosy-endemic countries points to the need to limit both the
number of skin sites and the frequency of smear collection to a minimum (see references).
 3

Multidrug Therapy (MDT)

From the list of activities, which are vital to the success of the Elimination Strategy, this New
Atlas concentrates on –

1. Early, correct diagnosis.

2. Differential diagnosis – i.e. a consideration of numerous other skin diseases which

may mimic leprosy and lead to the wrong diagnosis.

3. A detailed description of the blister packs and regimens in use for the treatment
of all patients with multidrug therapy (MDT).

The patient above was diagnosed by the health worker in the health centre, and is now
receiving his first blister calendar pack (BCP) of drugs for the treatment of multibacillary
(MB) leprosy.

Under WHO initiative, leprosy treatment is available for all patients, worldwide, free
of charge.

Some leprosy services have used a combination of rifampicin, ofloxacin and minocycline
(ROM), given as a one-time, single-dose for the treatment of single skin lesion (SSL)
leprosy; see pages 6 & 18 of Reference 2. Rifampicin is an essential component of the
regimens for both PB and MB leprosy, as described on the following pages. Ofloxacin and
minocycline are other antibiotics with proven action against the leprosy bacillus.
4
MDT (MB) – ADULT doses
Front view of the MB Adult MDT
blister pack

Monthly Supervised Treatment (DAY 1

– Top 2 lines break off: detachable):
Clofazimine 300mg (three capsules of
100mg), Rifampicin 600mg (two capsules
of 300mg) and Dapsone 100mg (one tablet
of 100mg)
Unsupervised Daily Treatment (DAYS
2–28): Clofazimine 50mg (one capsule of
50mg) EVERY DAY and Dapsone 100mg
(one tablet of 100mg) EVERY DAY
Duration of Treatment: 12 blister packs
to be taken within 12–18 months

Back view of the MB Adult MDT

blister pack

R = Rifampicin: monthly supervised dose is

600mg (2 capsules, each of 300mg).
C = Clofazimine 100mg: monthly
supervised dose is 300mg (3 capsules).
D = Dapsone: monthly supervised dose is
100mg (1 tablet).
The figures 2–28 represent 4 weeks of
unsupervised Clofazimine (50mg) every
day and Dapsone (100mg) daily.

Actual size of blister pack:

106mm x 140mm
 5
MDT (MB) – CHILD doses (age 10–14 years)
Front view of the MB Child MDT
blister pack

Monthly Supervised Treatment (DAY 1

– Top 2 lines break off: detachable):
Clofazimine 150mg (three capsules, each of
50mg), Rifampicin 450mg (two capsules,
one of 300mg, the other of 150mg) and
Dapsone 50mg (one tablet of 50mg)
Unsupervised Daily Treatment (DAYS
2–28): Clofazimine 50mg (one capsule of
50mg) EVERY OTHER DAY and Dapsone
50mg (one tablet of 50mg) EVERY DAY
Duration of Treatment: 12 blister packs
to be taken within 12–18 months

Back view of the MB Child MDT

blister pack
R = Rifampicin: monthly supervised
dose is 450mg (2 capsules, one of 300mg,
the other of 150mg).
C = Clofazimine 50mg: monthly
supervised dose is 150mg (3 capsules).
D = Dapsone: monthly supervised dose
is 50mg (1 tablet).
The figures 2–28 represent 4 weeks of
unsupervised Clofazimine (50mg) every
other day and Dapsone (50mg) daily.
Actual size of blister pack:
106mm x 140mm
For children below 10 years the dose may be adjusted: for
example Rifampicin 300mg, Dapsone 25mg and Clofazimine
100mg for the monthly, supervised dose, followed by
Dapsone 25mg daily and Clofazimine 50mg twice a week.
6
MDT (PB) – Adult doses
Front view of the PB Adult MDT
blister pack

Monthly Supervised Treatment (DAY 1

– Top line breaks off: detachable):
Rifampicin 600mg (two capsules, each of
300mg) and Dapsone 100mg (one tablet of
100mg)
Unsupervised Daily Treatment (DAYS
2–28): Dapsone 100mg (one tablet of
100mg) EVERY DAY
Duration of Treatment: 6 blister packs to
be taken within 6–9 months

Back view of the PB Adult MDT

blister pack

R = Rifampicin: monthly supervised dose

is 600mg (2 capsules, each of 300mg).
D = Dapsone: monthly supervised dose is
100mg (1 tablet).
The figures 2–28 represent 4 weeks of
unsupervised Dapsone (100mg) daily.

Actual size of blister pack:

72mm x 122mm
 7
MDT (PB) – CHILD doses (age 10–14 years)
Front view of the PB Child MDT
blister pack

Monthly Supervised Treatment (DAY 1

– Top line breaks off: detachable):
Rifampicin 450mg (two capsules, one of
300mg, the other of 150mg) and Dapsone
50mg (one tablet of 50mg)
Unsupervised Daily Treatment (DAYS
2–28): Dapsone 50mg (one tablet of
50mg) EVERY DAY
Duration of Treatment: 6 blister packs to
be taken within 6–9 months

Back view of the PB Child MDT

blister pack

R = Rifampicin: monthly supervised dose

is 450mg (2 capsules, one of 300mg, the
other of 150mg).
D = Dapsone: monthly supervised dose is
50mg (1 tablet).
The figures 2–28 represent 4 weeks of
unsupervised Dapsone (50mg) daily.

Actual size of blister pack:

72mm x 122mm

For children below 10 years the dose may be adjusted:

for example Rifampicin 300mg monthly, and Dapsone
25mg daily.
8
Before
MDT

After
MDT
The patient presented with a highly active nodular form of MB leprosy. She was treated
for 12 months with the MB regimen (page 4) and responded extremely well.
 9
Before
MDT

After
MDT
This boy presented with active widespread skin and nerve lesions of MB leprosy. He was
treated with the 12 months MB regimen, child doses (page 5) and responded extremely
well.
10

LEPROSY

Using the classification on page 2, the following images illustrate patients

with –

1. Paucibacillary (PB) leprosy, who by definition have 1–5 skin

lesions, and

2. Multibacillary (MB) leprosy, who have 6 or more skin lesions.

With the exception of two pictures on page 34, this Atlas does not include
information on the mainly neural or neurological aspects of leprosy. There
are numerous other publications on these important aspects of the disease,
several of which are given under References and Further Reading, on pages
74–76.

• These pictures are intended as an aid to recognition

and diagnosis
• In nearly all cases, leprosy can be diagnosed on
clinical signs alone
• When in doubt about the diagnosis, send the patient
to the nearest referral centre
 11

1. Paucibacillary (PB) Leprosy Cases

1. This schoolboy has a fairly well defined, coppery patch on his left cheek, which
is flat (macular). It was his only lesion. Careful testing revealed that he could not
feel light touch or pinprick on the patch. Paucibacillary (PB) leprosy.
12 PAUCIBACILLARY (PB) LEPROSY

2. This young girl has a widespread area of reduced colouring (hypo-

pigmentation) over the right cheek and side of the nose. Sensation testing
revealed that she could not feel cotton wool or pinprick on the patch.
Paucibacillary (PB) leprosy.
 PAUCIBACILLARY (PB) LEPROSY 13

3. There is quite a large area on the lower part of the back of the forearm,
with vague edges. This increased over a period of 2 months’ observation
and eventually showed reduced response to sensory testing. Paucibacillary
(PB) leprosy.
14 PAUCIBACILLARY (PB) LEPROSY

4. These vague, patches, with reduced

colouring (hypopigmentation) compared to
the surrounding skin, were found on the left
shoulder region. They increased in size
during a period of observation and showed
loss of sensation to cotton wool and pinprick.
Paucibacillary (PB) leprosy.
 PAUCIBACILLARY (PB) LEPROSY 15

5. This ring-like lesion was the only manifestation of leprosy. The surface,
particularly round the edge was raised, slightly rough and dry. The lesion showed
absent sweating, even after exertion. Loss of sensation to cotton wool and pinprick
was demonstrated. Paucibacillary (PB) leprosy.
16 PAUCIBACILLARY (PB) LEPROSY

6. This fairly extensive lesion on the back of the forearm had vague edges and,
on clinical examination with the fingers, felt slightly firm (infiltrated). Loss of
feeling to cotton wool and pinprick was easily demonstrated. Palpation of the
nearby ulnar nerve, with comparison with the nerve on the other side of the body,
was normal. Paucibacillary (PB) leprosy.
 PAUCIBACILLARY (PB) LEPROSY 17

7. This lady has a single, raised, well-defined lesion on the right cheek, with loss
of sensation. Paucbacillary (PB) leprosy. In lesions on the face which are early
and flat (macular), it may be difficult to demonstrate definite loss, or reduction
of sensation.
18 PAUCIBACILLARY (PB) LEPROSY

8. This picture shows a red lesion with raised edges on the upper surface of the
foot and ankle region. There was complete loss of feeling to cotton wool and
pinprick on the lesion. Paucibacillary (PB) leprosy.
 PAUCIBACILLARY (PB) LEPROSY 19

9. This boy shows a lesion over the left shoulder with reduced colouring
(hypopigmentation), with a tendency to form small ‘daughter’ or ‘satellite’
lesions beyond the main edge. There was definite loss of sensation to cotton wool
and pinprick. Paucibacillary (PB) leprosy.
20 PAUCIBACILLARY (PB) LEPROSY

1O. There is a large, well-defined lesion on the left buttock. The edge was raised
and firm on clinical examination with the fingers. Definite loss of sensation,
especially towards the edges, to cotton wool and pinprick. Paucibacillary
(PB) leprosy.
 PAUCIBACILLARY (PB) LEPROSY 21

11. An obvious, well-developed lesion is

shown on the right buttock, accompanied by
two, less obvious ones on the left. The main
lesion showed definite loss of sensation.
Paucibacillary (PB) leprosy.