Prevalence of plantar ulcer and its risk factors in leprosy: a systematic review and meta-analysis.

BACKGROUND: Plantar ulcers are a leading complication of leprosy that requires frequent visits to hospital and is associated with stigma. The extent of burden of ulcers in leprosy and its risk factors are scant impeding the development of targeted interventions to prevent and promote healing of ulcers. The aim of this review is to generate evidence on the prevalence of plantar ulcer and its risk factors in leprosy. METHODS: Databases (Medline, Embase, Web of Science, CINAHL, BVS), conference abstracts and reference lists were searched for eligible studies. Studies were included that reported a point prevalence of plantar ulcer and/or its "risk factors" associated with development of ulcers (either causatively or predictively), including individual level, disease related and bio-mechanical factors. We followed PRISMA guidelines for this review. Random-effects meta-analysis was undertaken to estimate the pooled point prevalence of ulcers. Reported risk factors in included studies were narratively synthesised. This review is registered in PROSPERO: CRD42022316726. RESULTS: Overall, 15 studies (8 for prevalence of ulcer and 7 for risk factors) met the inclusion criteria. The pooled point prevalence of ulcer was 34% (95% CIs: 21%, 46%) and 7% (95% CIs: 4%, 11%) among those with foot anaesthesia and among all people affected by leprosy, respectively. Risk factors for developing ulcers included: unable to feel 10 g of monofilament on sensory testing, pronated/hyper-pronated foot, foot with peak plantar pressure, foot with severe deformities, and those with lower education and the unemployed. CONCLUSIONS: The prevalence of plantar ulceration in leprosy is as high as 34% among those with loss of sensation in the feet. However, the incidence and recurrence rates of ulceration are least reported. The inability to feel 10 g of monofilament appears to be a strong predictor of those at risk of developing ulcers. However, there is a paucity of evidence on identifying those at risk of developing plantar ulcers in leprosy. Prospective studies are needed to estimate the incidence of ulcers. Identifying individuals at risk of ulcers will help design targeted interventions to minimize risk factors, prevent ulcers and promote ulcer healing.

Epidemiological clinical profile and closure of chronic plantar ulcers in patients with leprosy sequelae undergoing orthopedic surgery in a municipality in western Amazon.

INTRODUCTION: Chronic plantar ulcers in leprosy are lesions resulting from motor and sensory alterations caused by Mycobacterium leprae. They are lesions refractory to conventional dressings and present high recurrence rates. OBJECTIVE: To evaluate the epidemiological clinical profile of patients with chronic plantar ulcers associated with bony prominences in the lesion bed and to evaluate the efficacy of orthopedic surgical treatment of these lesions. METHODS: This is a descriptive and analytical retrospective study with the evaluation of medical records of patients undergoing surgical treatment of chronic plantar ulcers from 2008 to 2018. The surgical technique applied consisted of corrective resection of bone prominences and the primary closure of the lesion with bipediculated local flap. RESULTS: 234 patients were submitted to surgery, 55.1% male with an average age of 69.5 years old. Of these, 82.9% were illiterate; and 88.5% with open lesions over 10 years. After surgical treatment, total wound healing occurred in an average time of 12 weeks. The variables that contributed to shorter healing time were: Patients' lower age group; regular use of orthopedic shoes and insoles and dressings performed by nurse aides in health units before surgery. Obesity was the factor that correlated with the delay of healing time. CONCLUSION: A higher incidence was observed in males and male and female illiterate patients. The regular use of shoes and insoles and dressings performed by nurse aides in health units contributed to shorter postoperative healing time. Orthopedic surgical treatment with corrective resection of bony prominences proved to be an efficient therapeutic method for the closure of chronic plantar ulcers. It is a reproducible method, justifying the importance of the orthopedic surgeon in the context of the multidisciplinary team to cope with these complex lesions.

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.

Plantar ulcer occurrence among leprosy patients in Northern Nigeria: A study of contributing factors.

Background: The study was conducted in three major leprosy referral hospitals in Northern Nigeria, which are NKST Rehabilitation Hospital, Benue State, Yadakunya Leprosy Hospital, Kano, and National Tuberculosis/Leprosy Training Hospital, Zaria. The main objective of the study was to investigate factors responsible for the occurrence of ulcers among leprosy patients reporting to the leprosy referral hospitals. Materials and Methods: An analytic study of case-control design was used, with patients having plantar ulcers as cases and those without as control. Semi-structured was administered to all cases and controls. Results: A total of 242 patients were studied; 124 patients (51.2%) had plantar ulcers whereas 118 (48.8%) had no ulcers (controls). A Chi-square test was used in the analysis to compare cases and controls. The study found differences between cases and controls with respect to patients release from treatment (RFT), gender, availability and utilization of footwear, age, occupation, and educational status. Footwears were provided to most patients, i.e. 60.8% late (i.e., after developing plantar ulcers); however, there was very good utilization of the footwears among those who had the footwears, 65.3%. Knowledge of self-care was higher among 64.5% of cases compared to only 28.1% of the controls. Conclusion: Ulcer still remains a major problem among leprosy patients, especially RFT (76.6%) and most cases are provided with footwear late. Self-care knowledge is higher among cases than controls.

RésuméContexte: L'étude a été menée dans trois hôpitaux majeurs de référence pour la lèpre dans le nord du Nigéria, qui sont l'hôpital de réadaptation NKST, l'État de Benue, l'hôpital de la lèpre de Yadakunya, Kano et l'hôpital national de la tuberculose et de la lèpre, Zaria. L'objectif principal de l'étude était d'étudier les facteurs responsables de l'apparition d'ulcères chez les patients atteints de lèpre signalant des hôpitaux de référence pour la lèpre. Matériaux et méthodes: une étude analytique de la conception cas-témoins a été utilisée, les patients ayant des ulcères plantaires comme cas et ceux qui n'ont pas le contrôle. Semi-structuré a été administré à tous les cas et contrôles. sRésultats: Au total, 242 patients ont été étudiés; 124 patients (51,2%) avaient des ulcères plantaires tandis que 118 (48,8%) n'avaient pas d'ulcères (témoins). Un test du Chi-carré a été utilisé dans l'analyse pour comparer les cas et les témoins. L'étude a révélé des différences entre les cas et les contrôles par rapport aux patients libérés du traitement (RFT), le sexe, la disponibilité et l'utilisation de la chaussure, l'âge, la profession et le statut scolaire. Les chaussures ont été fournies à la plupart des patients, soit 60,8% en retard (c'est-à -dire après développement d'ulcères plantaires); cependant, il y avait une très bonne utilisation des chaussures parmi ceux qui avaient les chaussures, soit 65,3%. La connaissance de l'autosoins était plus élevée chez 64,5% des cas que dans seulement 28,1% des témoins. Conclusion: L'ulcère reste un problème majeur chez les patients atteints de lèpre, en particulier les TF (76,6%) et la plupart des cas sont munis de chaussures en retard. La connaissance des soins personnels est plus élevée parmi les cas que les témoins.

Fatores de risco para a ocorrência das úlceras plantares decorrente da hanseníase / Factors for plantar ulcers caused by leprosy

A hanseníase é doença infectocontagiosa de evolução lenta, causada pelo Mycobacterium leprae. A afinidade do bacilo da hanseníase por células do sistema nervoso periférico acomete, principalmente, os nervos superficiais da pele e dos nervos periféricos, causando neuropatia autonômica, sensitiva e motora que acarreta a diminuição ou ausência da sensibilidade e fraqueza muscular nos olhos, mãos e pés. Se não forem tratadas a tempo, podem provocar o surgimento de incapacidades físicas. Uma das incapacidades físicas mais comuns, vistas na prática clínica, são as úlceras na região plantar, que ocorre devido o comprometimento do nervo tibial, ocasionando déficits motores, sensitivos e autonômicos no trajeto do mesmo. O objetivo do estudo foi identificar os fatores de risco para a ocorrência das úlceras plantares em pacientes diagnosticados com hanseníase no Hospital Eduardo de Menezes da Fundação Hospitalar do Estado de Minas Gerais no período de 2005 a 2016. Trata-se de um estudo epidemiológico, do tipo observacional, transversal e analítico. A população foi composta pelos casos de hanseníase notificados no Hospital Eduardo de Menezes, no período de 2005 a 2016. Para a análise univariada foram utilizados os testes Qui-quadrado de Pearson ou teste exato de Fisher e teste de Mann-Whitney, com significância estatística de 5% (p < 0,05). Na análise multivariada por meio da árvore de decisão utilizando o algoritmo CHAID. Os resultados mostraram que forma clinica, grau de incapacidade física na alta, nervo acometido e o não uso de palmilhas ou calçado adaptado antes de surgir à úlcera se mostraram fatores de risco para a ocorrência de úlcera plantar. Foi identificado que entre os pacientes com grau de incapacidade 0 na alta, não existem casos de úlcera. Já entre aqueles com grau 1, e a forma clínica é DD ou DV a probabilidade de úlcera aumenta para 8,7%. Os pacientes com grau de incapacidade 2 na alta, nervo acometido tibial ou nervos fibular e tibial, mas que usavam palmilha ou calçado especial tem probabilidade de úlcera de 65,9%. Se o paciente não usava palmilhas ou calçados especiais antes de surgir à úlcera a probabilidade de ocorrência da úlcera aumenta para 95,7%. O presente estudo evidenciou a necessidade do diagnóstico precoce da hanseníase, como também da eficiente associação das intervenções medicamentosas e não medicamentosas por meio das técnicas de prevenção de incapacidade e uso de palmilhas acomodativas e/ou calçados especiais.(AU)

Leprosy is an infecto-contagious disease caused by Mycobacterium leprae. Leprosy bacillus' affinity for neural system cells affects mainly superficial skin nerves and periferal nerve roots, resulting in autonomic, sensitive and motor neuropathy, that leads to reduction or absency of sensitivity, and muscular weaknessin the eyes, hands and feet. If not timely treated, these can result in physical disabilities. Amid the most frequent physical disabilities seen in clinical practice are plantar ulcers, wich are caused by tibial nerve impairement, leading to motor, sensitive and autonomic deficits along tibial nerve trajectory. The objective os the present article was to identify risk factors for plantar ulcers in patients who were diagnosed for leprosy at Eduardo Menezes Hospital, Minas Gerais State Hospital Foundation, from 2005 to 2016. This is an epidemiological, observational, transversal, analytical study.The studied population was made of notified cases of leprosy, diagnosed at Eduardo de Menezes Hospital from 2005 to 2016. Pearson's qui-square, Fisher's exact test and Mann-Whitney's test, with 5% statistical significancy (p < 0,05), where used for univariate analysis. For multivariate analysis, CHAID algorythm decision tree was used. Results showed that clinical type, physical disability grade at the time of discharge, impaired nerve and absence of use of insoles or adapted shoes before the appearance of ulcers where risk factors for plantar ulcers ocurrence. For patients with 0 disability grade at discharge there where no cases of plantar ulcers. For those with grade 1 disability, clinical type was a relevant risk fator. For patients with grade 1 disability and type V or DT clinical types, probability was also zero. On the other hand, for DD and DV clinical types, probabilities rise up to 8,7%. Patients with grade 2 at discharge with or without fibular or other nerve impairement also have no probability of plantar ulcers ocurrence. AMong patients with grade 2 disability, tibial nerve impairment or both tibial and fibular nerve impairment, but who made use of insoles ou adapted shoes had a 65,9% probability of developing ulcers. In patients who do not use insoles ou special shoes before ulcer formation,probability of developing ulcers rises up to 95,7%. Present study has highlighted the need of early diagnosis of leprosy, and also the need of the use of efficient association of drug and non-drug techniques of disability prevention and use of insoles and/or special shoes.(AU)

Why person affected by leprosy did not look after their plantar ulcer? Experience from Pakokku zone, Myanmar.

A cross-sectional study was carried out to identify methods of caring plantar ulcers in leprosy patients and the underlying causes of poor plantar ulcer care during January and February 2008. This was conducted in Pakokku zone as it was one of the "9 selected townships of the Disabilities survey, i.e., Basic Health Staff project 2003/4", which was funded by Japan International Cooperation Agency. After getting consent, all available leprosy cases, i.e., 101 cases with foot disability grade 2 were interviewed with the pre-tested questionnaire. Among 101 cases, 13 cases who took care of their ulcer poorly and 20 who did none of the recommended measures were recruited for in-depth interview (IDI). The subjects were largely old people, males and people with no marriage partner. The majority had earned money by doing sedentary job. Prolongation of ulcers was observed in 78 cases. Most had been suffering from ulcers for years. When asking face-to-face interview, all the recommended care measures were not reported. Among these recommended measures, a large number of respondents reported about soaking measure. However, these reported measures were contradicted to the preventive methods which they disclosed in IDI. Plantar ulcer care seemed to be an individualised practice. The individual ways of performing were related to their view of ulcer, the environment, and occupation, and custom, communication with family and health staff. The findings identified the actual practice of plantar ulcer care in study areas. It is suggested that the current performance of planar ulcer care is inadequate and more attention should be given to achieve the target set by the programme as a recommendation.

Government health workers as implementers of prevention of disability measures: an assessment of a prevention of disability project in selected counties of Guizhou Province, Peoples' Republic of China.

OBJECTIVE: The purpose of this study was to assess the effectiveness of government health workers as agents for the prevention of disability. DESIGN: A prevention of disability (POD) project for people affected by leprosy was conducted in nine counties of Guizhou Province, Peoples' Republic of China. The project was implemented by government health workers. In accordance with the principles and national criteria of the National Centre for Leprosy Control (NCLC) POD Pilot programme, 1215 people affected by leprosy were selected, followed up and assessed with the use of impairment summary forms through which essential indicators were routinely collected. RESULTS: Most improvements of disabilities occurred in the 1st year of the POD project. Fifty five people with neuritis were detected and treated with prednisolone out of 262 new patients; 47 of these improved; 1130 people completed a 3-year self-care programme; 88.5% of red eyes, 83.9% of hand ulcers and 62.8% of simple foot ulcer cases healed during that period. One hundred and ninety six people who presented with complicated ulcers were treated; of these 73 (37.2%) people presented with feet free of ulcers at the end of the project period. CONCLUSION: The POD project was a cost-effective method of preventing further disability occurrence among people affected by leprosy. Government health workers were generally able to implement and monitor the project effectively. Most of people affected by leprosy were satisfied that the improvements in their disabilities had been due to self-care. The programme had helped them to increase their confidence to implement self-care activities.

Can people affected by leprosy at risk of developing plantar ulcers be identified? A field study from central Ethiopia.

In the ALERT leprosy control programme, 75 people affected by leprosy, in three different geographical areas, were investigated. Each person was documented as having anaesthesia to the 10 g monofilament. The study sought to determine why some people developed ulcers whilst others did not. According to the records, 43 had an ulcer during the last 5 years but 32 had never had an ulcer. In order to examine protective sensation on the sole of the foot, various sensory modalities were tested and the functional anatomy of the foot was examined. The results showed, as may be expected, that it is not possible to define a specific threshold for protective sensation that could be applied to all cases. Some people with only slightly diminished sensation developed ulcers, while many others with almost complete anaesthesia remained ulcer-free. In these rural communities, being a farmer reduced the risk of developing an ulcer, but no other demographic features were significant. Graded monofilaments were found to be the most appropriate test, with loss of sensation at any of five points tested being a 'positive' result. The 10 g filament was the most sensitive, but only 43% of feet identified by this test actually developed an ulcer. As people with partial loss of sensation were excluded from this study, this figure may be lower under programme conditions. The 50 g and 100 g filaments decrease the number of feet identified as at risk, but increase the percentage which actually develop an ulcer, to 46% and 49%, respectively. An appropriate test for selecting those for special programmes which may have a limited capacity, for example the provision of subsidized footwear or involvement in self-care groups, would be a 100 g filament, which would detect 86% of those feet likely to develop an ulcer, while reducing the number of those selected who are not at great risk. Vibrometry was found to be no better than graded filaments and an examination of functional anatomy did not help in identifying those at risk.

Management of simple plantar ulcers by home based self-care.

Seeking a solution to bring down the prevalence of simple plantar ulcers in the field, Damien Foundation India Trust (DFIT), Chennai, developed a curriculum to teach the field staff of all its projects. The purpose was to make patients self-reliant in the care of their plantar ulcers in their homes. The strategy used was to make patients take care of their ulcers using tools found in their homes and surroundings and become responsible for the care of their limbs. This strategy was implemented in eight projects of DFIT and the programme was followed regularly for one year. Regular monitoring and evaluation showed that under this strategy the prevalence of plantar ulcers was reduced by about 50%.

[The frequency of the appearance of perforating foot ulcers in patients with Hansen's disease as a function of treatment with disulone alone or with polychemotherapy]. / Fréquence d'apparition de maux perforants plantaires chez des malades hanséniens en fonction du traitement par disulone seule ou polychimiothérapie.

Between 1986 and 1989, in 5 departments of Senegal, 436 new cases of leprosy were detected, of whom 225 were put under dapsone monotherapy and 211 under multidrug therapy (MDT). Of them, 190 could be followed-up during 2 years by means of annual bacteriological and clinical examination, including neurological assessment. In 2 years, the onset of 10 (5.3%) chronic plantar ulcers (CPU) was observed: 4 (4%) among the 99 patients under dapsone monotherapy and 6 (6.6%) among the 91 under MDT (no significant difference). Of the 10 CPU, 3 (2%) appeared among the 149 patients without any disability at detection while 7 (17%) were observed among the 41 others who presented a grade 1 disability at detection (p < 0.01). Of the 6 CPU appeared in the patients under MDT, 5 (22%) were observed among the 23 who presented a grade 1 disability at detection and 1 (1.5%) among the 68 who did not (p < 0.01). This difference was not noted in the patients under dapsone monotherapy. Our results need to be confirmed by other studies including a higher number of patients followed-up during a longer period of time. Nevertheless, they suggest that MDT could prevent the onset of CPU, but only in patients without any disability at detection. Therefore, they reemphasize the importance of early detection of the disease in leprosy control programmes.

[Characterization of chronic plantar ulcers in former leprosy patients]. / Cancérisation des plaies chroniques plantaires chez les anciens malades de la lèpre.

Between 1988 and 1992, 21 biopsies for pathological examination were taken from 20 Senegalese leprosy patients suffering from chronic plantar ulcers (CPU) suspected of malignant transformation. The diagnosis of squamous cell carcinoma was effectively made in 13 cases and that of pseudoepitheliomatous hyperplasia in the remaining 8 cases. The mean period of time between the onset of CPU and that of malignant transformation was 10 years (range: 1 to 15 years); the mean annual frequency of the malignant transformation was 2 per 1,000 CPU. In countries where pathological examination is not available, below knee amputation could be considered whenever main clinical signs of malignant transformation are present. In countries where pathological examination is available, the therapeutic decision may differ according to the diagnosis: below knee amputation supplemented with block dissection of inguinal lymph nodes whenever possible in cases of carcinoma; below knee amputation depending on the function status of the foot and on the volume of tumor in case of pseudo-epitheliomatous hyperplasia.