Comorbidities associated with non- healing of plantar ulcers in leprosy patients.

BACKGROUND: Non-healing plantar ulcers are one of the significant causes of disability in leprosy patients. Plantar ulcers often take months or years to heal, affecting the patient's quality of life. Presence of comorbid conditions in these patients can delay wound healing. The study aimed to evaluate the role of associated comorbid conditions as risk factors in ulcer healing. METHODOLOGY/PRINCIPAL FINDINGS: A total of 66 leprosy patients with plantar ulcers registered at LEPRA Society-Blue Peter Public Health and Research Center (BPHRC), Hyderabad, India from June 2018 to June 2019 were studied. Comprehensive clinical assessment was done, including screening for comorbid conditions and treated as per the recommended guidelines. About two-thirds of the participants were aged 50 and above, of which more than half were illiterates, and 93.5% were living below the poverty line. Majority of ulcers were seen on the forefoot; with the head of meta-tarsal bone 27 (41.6%) as the commonest site, followed by calcaneum 23 (38.3%) and great toe 10 (16.6%). Mean ulcer depth was 0.61 (0.57) cm, the area was 5.24 (6.73) cm2 and ulcer volume was 4.72 (14.33) cm3. Ulcer dimensions were significantly associated with low body mass index, hypertension and smoking. CONCLUSIONS/SIGNIFICANCE: Identifying the risk factors delaying wound healing and detailed assessment of ulcers are of profound importance to predict the outcome of plantar ulcers in leprosy patients. The study findings indicate the need for better policies by the leprosy control program for the comprehensive management of plantar ulcers.

Tratamento da úlcera plantar devido à hanseníase / Treatment of leprosy-induced plantar ulcers

Introdução: A úlcera plantar por hanseníase é uma lesão no pé resultante da falta de sensibilidade plantar. O objetivo é descrever o tratamento realizado em portadores de úlceras plantares por hanseníase. Métodos: Estudo de prontuários de portadores de úlcera plantar atendidos no Hospital Sarah em Brasília, de 2006 a 2016, quanto ao sexo, idade, etiologia, localização e tratamento. Resultados: Foram atendidos 27 pacientes, 17(62,96%) homens e 10 (37,04%) mulheres, procedentes de Goiás e DF, na faixa etária de 41 a 60 anos (40,74%). Todos necessitaram de um ou mais procedimentos cirúrgicos. Conclusão: Observou-se maior frequência no sexo masculino, grau avançado, localizadas no primeiro artelho. Todos necessitaram de procedimentos cirúrgicos e não cirúrgicos, evoluindo com cicatrização completa da ferida, amputação transtibial em um caso e de artelhos em sete casos, e 90% dos casos apresentaram recorrência da úlcera após um ano.

Introduction: Leprosy-induced plantar ulcers result from a lack of plantar sensitivity. Objective: This study aimed to describe the treatment provided to patients with leprosy-induced plantar ulcers. Methods: We retrospectively reviewed the medical records of patients with plantar ulcers treated at Sarah Hospital in Brasilia from 2006 to 2016 and collected information about sex, age, etiology, location, and treatment. Results: A total of 27 patients (17 [62.96%] men, 10 [37.04%] women; 40.74% were aged 41­60 years) were treated from Goiás and the Federal District. All required ≥1 surgical procedure. Conclusion: A higher frequency of advanced grade was observed in men, primarily on the first toe. All needed surgical and non-surgical procedures and achieved complete wound healing. Transtibial amputation was required in 1 case and toe amputation in 7 cases; 90% patients developed ulcer recurrence after 1 year.

Polyhexanide 0.2% in treatment of trophic foot ulcers in leprosy - preliminary study.

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, which affects peripheral nerves, skin and mucous membranes. The impairment of neural function as well as sensory or sensory-motor disabilities in leprosy continue to be a problem that requires careful attention in the management of patients with the aim to avoid or minimize their progression to prevent sequelae. One of the most common characteristics of these ulcers is the tendency to chronicity, with variable therapeutic response. In this article, we shall discuss the therapeutic management of thirteen trophic leprosy ulcers in eight patients using polyhexanide 0.2% products.

Polyhexanide 0 2% in treatment of trophic foot ulcers in leprosy - preliminary study

Abstract: Leprosy is a chronic infectious disease caused by Mycobacterium leprae, which affects peripheral nerves, skin and mucous membranes. The impairment of neural function as well as sensory or sensory-motor disabilities in leprosy continue to be a problem that requires careful attention in the management of patients with the aim to avoid or minimize their progression to prevent sequelae. One of the most common characteristics of these ulcers is the tendency to chronicity, with variable therapeutic response. In this article, we shall discuss the therapeutic management of thirteen trophic leprosy ulcers in eight patients using polyhexanide 0.2% products.

The story of a deformed leprous foot.

Eccrine syringofibroadenoma (ESFA) is a rare adnexal tumour of eccrine ductal proliferation. A 50 year old treated case of leprosy presented with a chronic non healing ulcer of 5 years duration on the deformity laden right foot. Multiple verrucous papules and plaques were seen surrounding the ulcer which showed histopathological findings consistent with ESFA. Although ESFA constitutes a rare association with leprosy, considering the load of treated cases in our country and elsewhere, it may represent an under-reported entity which requires more attention in the post elimination era.

Nodular melanoma in trophic ulceration of a leprosy patient: a case study.

UNLABELLED: Non-healing chronic trophic ulceration is very common in leprosy patients. Marjolin's ulcer consists of the malignant transformation of a chronic ulcerative lesion. Nodular melanoma developing from Marjolin's ulcer, caused by a trophic ulceration of a leprosy patient, is very rare with only a few cases reported in the literature. Due to the disguised presentation of these malignancies within trophic ulceration lesions in leprosy, neoplastic transformation is frequently overlooked, leading to misdiagnosed and delayed treatment. This paper reports a case of an 83-year-old man with lepromatous leprosy and chronic ulceration on the foot for 22 years. Over a period of 2 months, the ulcer enlarged, turned black, and became more painful. The patient underwent regional excision and immunotherapy after the diagnosis of malignant nodular melanoma. After 9 months follow-up, no metastasis was found. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Health beliefs surrounding leprosy induced foot ulceration; an exploratory qualitative study from South Nepal.

UNLABELLED: Leprosy is a complex and multi-faceted disease responsible for significant disability in several endemic countries. Physical impairments caused by leprosy are often amplified by local sociocultural phenomena in many parts of the world. In Nepal, sociocultural phenomena such as stigmatisation and health beliefs affecting treatment compliance and health seeking behaviours are known to play an important role in the acquisition of disability. Foot-ulceration is reported to be a common sequelae of leprosy, however, presently little research has been published investigating the potential influence of patient beliefs on management of foot ulceration in leprosy affected persons. OBJECTIVE: In light of this we conducted an exploratory qualitative study to investigate the health beliefs held by patients with foot ulceration at a Leprosy hospital in Nepal. METHODS: A mixture of open-ended interviews (n = 21), three focus groups and a series of field observations were used to explore the explanatory models of foot ulceration thought to be used by leprosy affected people to understand and explain this specific comorbidity. RESULTS: Our findings indicated that a wide range of health beliefs were present in our sample, many of which lie outside of the biomedical understanding of illness. This included a range of non-biomedical beliefs regarding wounds and widespread application of the traditional 'hot-cold' model of illness used to explain foot ulceration. DISCUSSION: The findings of this study appear to suggest many beliefs held by leprosy affected persons concerning foot ulceration are highly complex, with some expressed beliefs potentially having a negative impact on self-management of ulceration.

[Malignant transformation of plantar ulcers in leprosy: experience of National Leprosy Center in Casablanca]. / Dégénérescence carcinomateuse des maux perforants plantaires d'origine lépreuse: expérience du Centre national de léprologie de Casablanca.

Malignant degeneration is a late complication of plantar ulcers in leprosy. The objective of this study is to describe and analyze the epidemiological, clinical, and therapeutic aspects of this complication in Morocco. A retrospective study was conducted from January 2000 to December 2009 at the National Center of Leprosy (CNL) in Casablanca. All our patients had a histological confirmation. Ten patients were included in this study. There were seven men and three women, with a mean age of 58.8 years. Six patients had a multibacillary form of leprosy and four had a paucibacillary form. The average duration of the plantar ulcers was 34.4 years. Clinical appearance at diagnosis was an ulcerative and vegetative tumor. Treatment was by radical amputation. Evolution was marked by metastatic spread in six patients. One patient died of disseminated disease. In Morocco, leprosy has been on the decline since 1990, but the occurrence of late complications in the leprosy patient as carcinoma of plantar ulcers persists. Prevention of these complications should be part of the national fight against leprosy.

[Two cases of leprosy related conditions and relevant issues on medical services for ex-leprosy patients who live in communities in Japan].

In Japan people affected by leprosy who were forced to admit to national leprosy sanatoria under leprosy prevention/segregation law (1953) have ever been promoted to return to live in community, after destruction of the law in 1996. In this paper two cases are shown with some comments who had already been discharged from leprosy sanatoria and came late to OPD of National Suruga Sanatorium for consultations of their leprosy related conditions. One case is a 60 year-old male who developed squamous cell carcinoma (SCC) from chronic planter ulcer. The other is a 69 year-old female who developed relapse after more than 20 years BI negativity. In these cases, periods until consultation to our clinic were one year and five months, and five years and five months respectively. One reason is that there is no follow-up system of leprosy related conditions for ex-patients in current medical service of Japan. Another reason may be that patients hesitated to consult local doctors for their leprosy related conditions. Since national leprosy sanatoria will come to be closed in near future, services should be available for leprosy related conditions, such as prevention of disability (POD), prevention of worsening disability (POWD), early detection of relapse and leprosy reaction, in general medical service of Japan.

Shewanelia putrefaciens: a rare microbial agent associated with a non-healing ulcer in a leprosy patient.

Female aged 55 years presented with signs and symptoms of borderline lepromatous leprosy and presence of a non-healing ulcer and multiple haemorrhagic blisters over dorsum of both feet. Discharge from the various lesions was subjected to microbiological examination and an unusual organism Shewanella purtefaciens was isolated which was sensitive to most routine antibiotics. Patient responded well to cephadroxil therapy with uneventful and complete healing of ulcer and blisters.

The sustainability of self-care in two counties of Guizhou Province, Peoples' Republic of China.

This paper presents the findings of a follow-up survey conducted in two rural counties of Guizhou Province, PRC where a programme to prevent disabilities amongst leprosy affected people had been conducted. An initial 3-year programme had been conducted. One year after the final evaluation of the programme, a team was deployed to conduct a survey in the area. The objective of the survey was to establish the level of adherence to self-care. It was found that 87% of the sample of people living in leprosy villages that were surveyed (n = 31) and 50% of the sample of people living in general communities (n = 50) had continued to apply self-care. Interviews with family members suggested that 18 of the 27 self-care practising subjects living in the leprosy villages received encouragement or active support from family members (9 were single people). Twenty three of the 25 self-care practising subjects living in the communities also received family support (2 were single people). Family support was a highly significant factor influencing adherence in the community (OR = 15.8, CI = 3.0 to 83) but it may not have been the primary motivating factor in the leprosy villages where single people were just as likely to have adhered to self-care than people who were living in families (OR 0.5, CI = 0.06 to 4.2). The prevalence of foot ulceration among that population was recorded but a hypothetical association between the prevalence of foot ulceration and self-care adherence could not be investigated due to insufficient data to address the potential effects of confounding variables. Thirty-eight percent of subjects who did not practice self-care presented with ulceration or foot cracks (n = 29) compared with only 25% of people who did (n = 52).

Squamous cell carcinoma in plantar ulcers in leprosy: a study of 11 cases.

The objectives of our study were to describe and analyse the malignancies that occurred in plantar ulcers of leprosy patients. The possible predisposing conditions, duration and extent of the spread of the tumour were also studied. All patients with trophic ulcer of the foot attending the urban leprosy clinic in our hospital from January 1998 to January 2003 were screened for change to malignancy. During the study period, 79 cases of plantar ulcers in leprosy were seen. The mean age of these cases was 39.9 years with male-to-female ratio of 4:1. Eleven cases with plantar ulcers and malignant change were diagnosed in our hospital during the study period. The male-to-female ratio was 4.5:1. The mean age of these patients was 60.6 years. Their age ranged from 46 to 75 years. Nine of the cases were treated cases of borderline tuberculoid leprosy, while two had treated lepromatous leprosy. In our study, two distinct morphological types of malignant changes were seen. Histopathologically, all cases, except one, were of well-differentiated squamous cell carcinoma variation; one case had verrucous carcinoma. Though trophic ulcers are common in leprosy cases, only long-standing and neglected ones undergo malignancy.

[How does one treat the osteitis and osteoarthritis of the extremities in older leprosy patients using granulated table sugar?]. / Comment guérir les ostéites et ostéo-arthrites des extrémités des anciens malades de la lèpre par le sucre cristallisé alimentaire?

A common problem of osteitis and septic arthritis is the recurrent bone infection after surgical debridement, a problem frequently encountered in patients with sequela leprosy. In these cases the authors propose the use of an ancient method of post surgical wound care based on the treatment with ordinary granulated sugar. The hyperosmolar climate created this way in the wounds inhibits the bacterial growth, enhances bacterial death and therefore permits the growth of granulation tissue in order to recover the debrided nude bones. At ILAD (Leprosy Institute of Dakar), 36 osteitis and septic arthritis were treated and healed during the last 2 years from March 1995 to March 1997 using this technic. All the wounds healed in the mean-time of 44 days. Only two of them needed a second debridement and healed afterwards. Up to now the method using ordinary sugar was applied in the treatment of infected wounds, eschars and postsurgical infections. Our experience shows that it also can be indicated to treat bone infections. This method is easy to apply also under often difficult field conditions and is very cheap.

Squamous cell carcinoma of the foot arising in chronic ulcers in leprosy patients.

Squamous cell carcinoma (SCC) of the foot is a rare sequelae of chronic ulceration secondary to leprosy neuropathy. Most of the tumours are relatively slow growing and tend to metastasize late. Survival after local excision is generally good. In this series of 17 patients so far there have been 3 deaths attributable to SCC, all of whom presented with locally advanced tumours and lymph node metastasis.

[Squamous cell carcinoma in neuropathic plantar ulcers in leprosy: another example of Marjolin's ulcer]. / Plaveiselkarsinoom in neuropatiese plantare ulkusse van leprose: nog 'n voorbeeld van Marjolin se ulkus.

Seven cases of squamous cell carcinoma (SCC) arising in chronic neuropathic plantar ulcers of leprosy are described. These patients (average age 59 years) presented over a 5-year period. The mean duration of neuropathic ulceration until diagnosis of SCC was 24.5 years. Six patients required limb amputations and 3 underwent lymphadenectomy for involved nodes. One patient died of disseminated disease. The history of the eponym "Marjolin's ulcer' is traced and a case put forward for recognition of malignant change in neuropathic ulcers as yet another example of Marjolin's ulcer. A plea is made for an increased awareness of the possibility of malignant transformation in chronic neuropathic ulcers in order to effect an early diagnosis of a potentially aggressive cancer. This is the first report of its kind in South Africa. Similar cases, however, have been reported from other parts of the world where leprosy is endemic.

Vascular surgery of the posterior tibial compartment for plantar ulceration in leprosy.

Traditional surgical decompression of the posterior tibial nerve yields equivocal results. The authors postulate that the posterior tibial artery is the most compromised structure in the neurovascular compartment and that the best surgical results in healing of plantar ulcers are achieved by the rechannelling of the blood flow in the posterior tibial artery during posterior tibial neurovascular compartment surgery. This procedure has been of benefit to patients with plantar ulcers of greater than 7-10 years' duration in whom all other modes of healing had failed. It has been undertaken as an outpatient procedure under local anaesthesia, supported by postoperative vasodilator drugs. The use of tourniquet, antibiotics and surgical interference with the ulcer per se was eschewed. A report of 156 patients is presented with follow-up of up to 6 years for the earlier cases.

Squamous cell carcinoma in plantar ulcers in leprosy. A case control study.

The objective of this case-control study was to identify factors associated with the development of squamous cell carcinoma (SCC) in plantar ulcers of leprosy patients. We examined 2 matched groups consisting of leprosy patients with and without SCC in a plantar ulcer. No correlations were found between the development of SCC and race, profession, place of origin, duration of leprosy, the type and duration of leprosy chemotherapy, presence of bone involvement and type of ulcer care treatment given. The only statistically valid finding was that the duration of the ulcer was significantly lower in the group with malignant change. In this group there was an apparently higher use of pesticides, the difference being not of statistical significance. It is concluded that factors other than ulcer duration need to be looked for, in order to identify factors influencing malignant change in plantar ulcers of leprosy patients.