A 38-year-old man from rural Maharashtra presents with a 2-year history of hypopigmented macules on his trunk and arms with loss of sensation in the affected areas. On examination, he has 5 well-demarcated lesions, thickened ulnar and posterior tibial nerves, and mild weakness of the intrinsic hand muscles. Slit-skin smear from the lesion shows 2+ acid-fast bacilli. He is HIV-negative and has no prior leprosy treatment. What is the most appropriate MDT regimen for this patient?

Explanation

## Classification and MDT Selection This patient presents with **borderline tuberculoid (BT) leprosy** based on: - 5 well-demarcated lesions - Moderate nerve thickening and early nerve damage - Moderate bacillary load (2+ on slit-skin smear) - Clear sensory loss in lesions ### WHO Classification of Leprosy | Feature | TT | BT | BB | BL | LL | |---------|----|----|----|----|----| | **Number of lesions** | 1–5 | 5–15 | >15 | Many | Innumerable | | **Bacillary load** | 0 | 1–2+ | 3–4+ | 4–5+ | 5–6+ | | **Nerve involvement** | Mild | Moderate | Moderate–severe | Severe | Severe | | **MDT duration** | 6 months | 12 months | 12 months | 12 months | 12 months | ### MDT Regimen for BT Leprosy **Key Point:** BT leprosy (5–15 lesions, 1–2+ bacilli) requires **12-month MDT** with **three drugs**: 1. **Rifampicin** 600 mg once monthly (supervised) 2. **Dapsone** 100 mg daily (unsupervised) 3. **Clofazimine** 50 mg daily (unsupervised) **High-Yield:** The 12-month regimen is essential for BT and all lepromatous forms to prevent relapse and drug resistance. Shorter courses (6 months) are only for TT leprosy. **Clinical Pearl:** Clofazimine is critical in multibacillary disease because it prevents dapsone resistance and has anti-inflammatory properties that reduce erythema nodosum leprosum (ENL) risk. [cite:Park 26e Ch 9]