A 38-year-old man from rural Maharashtra presents with a single hypopigmented patch on his left forearm with loss of sensation. On examination, the patch is well-demarcated and anaesthetic. Slit-skin smear examination shows acid-fast bacilli. He has no signs of nerve thickening or systemic involvement. What is the most appropriate next step in management?

Question

Accepted Answer

D. Start multidrug therapy (MDT) for paucibacillary leprosy immediately. ## Clinical Assessment & Classification

This patient presents with **indeterminate/tuberculoid leprosy** (single lesion with sensory loss). The slit-skin smear positivity confirms mycobacterial infection, and the clinical picture is consistent with paucibacillary disease.

**Key Point:** Once leprosy is clinically suspected and confirmed by slit-skin smear positivity, MDT should be initiated without delay. Delaying treatment increases the risk of nerve damage, disability, and transmission.

**High-Yield:** WHO classification of leprosy is based on:
- Number of skin lesions (≤5 = paucibacillary; >5 = multibacillary)
- Slit-skin smear positivity (negative = paucibacillary; positive = multibacillary)
- Nerve involvement

In this case, despite slit-skin smear positivity, the single lesion and absence of nerve thickening suggest **paucibacillary disease**.

**Clinical Pearl:** Paucibacillary leprosy can show positive slit-skin smears in early lesions; the WHO classification prioritizes the number of lesions and clinical signs over smear status alone.

## MDT Regimen for Paucibacillary Leprosy

| Component | Duration | Frequency |
|-----------|----------|----------|
| Rifampicin | 6 months | Monthly supervised |
| Dapsone | 6 months | Daily self-administered |
| Clofazimine | 6 months | Daily self-administered |

**Key Point:** Treatment should begin immediately upon diagnosis to prevent irreversible nerve damage and disability.

## Why Immediate Treatment?

1. **Prevention of nerve damage** — M. leprae multiplies slowly but causes progressive demyelination
2. **Reduction of infectivity** — Rifampicin renders patients non-infectious within 2 weeks
3. **WHO guideline** — MDT is the standard of care; no additional confirmatory tests are required once clinical diagnosis + smear positivity are established
4. **Disability prevention** — Early treatment halts progression and prevents type 1 and type 2 lepra reactions

Answer

A. Perform nerve palpation and assess for nerve thickening before initiating treatment

Answer

B. Refer to a tertiary centre for confirmation by PCR before starting any treatment

Answer

C. Obtain a skin biopsy for histopathological confirmation before commencing MDT

Explanation

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