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Leprosy is among the world's oldest and most dreaded diseases and it has been synonymous with stigma and discrimination due to the hideous deformities it produced, mystery around its aetiology and transmission and lack of any effective remedy till recently. Leprosy control started with the use of chaulmoogra oil and for the last three decades, multi drug therapy (MDT) has been our main tool against leprosy. In the last two decades, the reported global prevalence of active leprosy infection has dropped by almost 90 per cent by the combined efforts of the World Health Organization (WHO), local governments, health professionals, and non-governmental organizations (NGOs), however, a parallel drop in the incidence or new case detection rate (NCDR) has not occurred. From 1994 through 2011, more than 100,000 new cases are being detected annually, of whom maximum case load is from India. There is need for research on tools for early diagnosis, short and effective treatment, and prevention of deformities and disabilities. Evaluating the role of immunotherapy and immunoprophylaxis will also lead us to better understanding of their mode of action. Further molecular analysis of Mycobacterium leprae genome may provide the requisite basis for all this. The current reality is that there is a need to sustain and provide quality leprosy services to all persons through general health services, including good referral system. All these provisions in the integrated health care approach will go a long way in further reducing the stigma. Efforts need to be made to reduce deformity through early detection, self care, physiotherapy and reconstructive surgery and developing sound surveillance systems. With all the remarkable achievements in the fight against leprosy, the stage is now set for the final assault. It is hoped that with the efforts of all the stake holders and strong political will, the disease will be eradicated in the near future.

In leprosy on treatment, one factor contributing to the healing of skin lesions with minimal fibrosis may be apoptosis of inflammatory cells, even though apoptosis is sparse in leprosy as compared to tuberculosis. The degree of apoptosis in skin lesions of leprosy was studied by histopathologic examination (HPE) and by DNA fragmentation and electrophoresis. The effect of various parameters on apoptosis was noted in untreated disease, during treatment at 3 and 6 months, and in lepra reactions in different parts of the spectrum of leprosy. Of the 31 patients, 13 had paucibacillary (PB) and 18 multibacillary (MB) disease. Twenty one patients were in reaction: 16 had type 1 reaction and 5 had type 2 reaction. The controls included patients with non-granulomatous skin diseases; there were no normal controls, and no separate controls for cases with reaction. Apoptosis occurred more frequently in patients with leprosy as compared to the controls. In both PB & MB lesions, apoptosis was observed to increase progressively with treatment at 3 and 6 months, and was more prominent in the MB cases at 6 months of treatment. When lesions in either type 1 or type 2 reaction were compared to lesions not in reaction, a significant increase in apoptosis (p = 0.014) was found only in lesions with type 2 reaction and those which were at 6 months of treatment. The type of treatment regimen, or oral steroids given for reactions, did not significantly alter the degree of apoptosis. Our observations indicate that increased apoptosis is present in leprosy lesions and that in leprosy it progressively increases with anti-leprosy treatment up to 6 months. If the process of apoptosis in skin lesions is followed up for a longer period of time, the degree of apoptosis may be expected to decline. The study of apoptosis may help to understand the mechanism of clearance of bacilli and resolution of granulomas in leprosy patients.

Three hundred leprosy patients were recruited to study the pattern and frequency of nail changes. Nail changes, like longitudinal ridging in finger nails, transverse striations involving both finger and toe nails etc. which occurred with similar frequency in the PB and MB patients in comparison with the control group, were excluded from the analysis. Out of a total number of 150 PB patients, 84 (56%) showed nail changes. Fifty-eight (38.6%) patients showed changes in the finger nails, with an average of 3.2 involved nails per patient. Fifty-three (35.3%) patients showed changes in the toe nails, with an average of 3.0 nails per patient. The most common change observed was longitudinal melanonychia (32.4%) in the finger nails and longitudinal ridging (46.3%) in the toe nails.In comparison, 131/150 (87.3%) MB patients showed nail changes. Finger nail changes were seen in 102 (68%) patients with an average of 5.5 nails affected per patient. Changes in toe nails were seen in 116 (77.3%) patients, with an average of 6.0 nails involved per patient. The most common nail change observed was longitudinal melanonychia in 89/523, (17%) of the total involved finger nails and subungual hyperkeratosis in 164/702, (23.4%) of the total toe nails involvement. Out of a total of 32 colony patients, 31 (96.9%) showed nail changes both in finger and toe nails with an average of 7.9 and 8.4 affected nails per patient, respectively. The most common nail change observed was rudimentary nail(s) on fingers (29%) and toes (21.1%). Among MB patients, a significantly higher number had finger nail involvement in LL group. The frequency of nail involvement for both fingers and toes was significantly greater in LL as compared to BL group of patients. The frequency of nail involvement was significantly more in patients having disease for more than 5 years and in those having trophic changes secondary to loss of sensations and impaired circulation.

In this study, clinically all forms of lesions like macules, plaques, and nodules were found in all the "relatively spared zones," except groins. Histopathology confirmed that the disease process was established and the acid-fast bacilli were not present as a part of bacteremic settlement. Hence, it appears that practically no area on the surface of skin is immune to invasion by M. leprae. However, as the incidence of lesions and AFB in these regions is relatively less, especially over axilla and groin, these areas can be considered as relatively spared zones but not completely resistant to development of lesions of leprosy.

A total of 136 patients with BI > or = 2 having been followed up for at least 2 years or more were included in the analyses. Seventy-seven out of 136 patients had completed three years follow up. All patients were given WHO/MDT MB regimen for 12 months and additionally 4 doses of Mycobacterium w. vaccine at 3-month intervals. The age of the patients varied from 6 to 77 years (mean 34 +/- 11.3 years) and they had the disease varying from 3 months to 7 years (mean = 1.9 +/- 1.4 years). The mean of the BI before starting treatment was 3.6 +/- 1.3. At the end of 2 years follow-up, a total of 54 patients out of the 136 (39.7%) had become smear-negative. A larger proportion of patients, 39/46 (84.8%) with BI of < or = 3 had become smear-negative, whereas, only 10/32 (31.3%) patients with BI between 3.1 to 4 and 5/58 (8.6%) highly bacillated patients having initial BI > 4 had become smear-negative at the end of 2 years. Out of the 77 patients who were available for follow up at 3 years, 30/33 (90.9%) patients with BI of < or = 3, 15/20 (75%) patients with BI between 3.1 to 4 and 13/24 (54.2%) patients having initial BI > 4, respectively, had attained smear negativity. Reactions occurred more frequently after 6 months of therapy and over a period of time their frequency gradually decreased, however, they continued to occur even two years after RFT. During the course of MDT and thereafter in follow up 4.6% and 1.3% of the patients developed new deformities or an increase in the existing grade of deformities, respectively. Three relapses (2 in LL and 1 in BL) occurred in patients having initial BI of > 4. One patient relapsed in the second year and the other two relapsed in the third year of follow up and were successfully treated with reintroduction of the same MDT MB regimen. Local ulceration healing with scar formation and regional lymphadenopathy were the only local reactions to the vaccine seen in 47/136 (34.5%) patients. All the patients showed histopathological improvement in the form of a gradual reduction of granuloma fraction. Although the results of this limited period follow up are satisfactory, a long-term follow-up in larger number of patients will settle the issue of safety and efficacy of shortened MDT MB regimen and the place of immunotherapy with M. w. vaccine in multibacillary patients.

The article offers the authors' insights on the use of single-dose rifampicin (SDR) for treatmet of leprosy. Topics mentioned include the use of SDR treatment by the Indian National Leprosy Programme, the effectiveness of SDR to leprosy patient, and the importance of early detection and treatment of leprosy to prevent physical defornity. Also mentioned are the rifampicin drug resistance and the relapsed leprosy in several countries such as Brazil and India.

Leprosy, also known as Hansen's disease, an ancient affliction of mankind, is still endemic in some countries. The fear and stigma associated with the disease arised from the unsightly deformities due to nerve damage and anesthesia. Historically, mono- and multidrug therapies have been used in a range of combinations for various durations with variable results and degrees of compliance. WHO-recommended multidrug therapy has proved to be the most important landmark in the chemotherapy of leprosy with a tremendous success in the control of the disease, significant fall in the number of patients worldwide and acceptable relapse rates. Research for more effective and bactericidal drugs is in progress. Intensive short-course regimens and uniform schedules all along the spectrum are being evaluated in field trials. Care of patients with nerve function impairment, reactions, relapses and prevention of disabilities and rehabilitation will remain an imperative task for healthcare providers even in the post-elimination era. Integration of leprosy with general health services in all endemic countries poses a challenge for early diagnosis and proper management of disease, including reactions, prevention of disabilities, imparting quality training to primary healthcare workers and maintaining required expertise at the referral level. It is hoped that the newer and more effective patient-friendly regimens combined with the positive approach of national and international agencies could lead to leprosy becoming a historical disease. [ABSTRACT FROM AUTHOR]