Leprosy (Hansen’s Disease)

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Leprosy Nursing Care Management
Nursing study guide for leprosy.

The social and psychological effects of leprosy, as well as its highly visible debilities and sequelae, have resulted in a historical stigma associated with leprosy. Review this study guide and learn more about leprosy or Hansen’s disease, its nursing care management, interventions, and assessment.

What is Leprosy?

Hansen’s disease (also known as leprosy) is an infection caused by slow-growing bacteria called Mycobacterium leprae.

  • To minimize the prejudice against those with leprosy, the condition is also known as Hansen disease, named after G.A. Hansen, who is credited with the 1873 discovery of M leprae.
  • These bacteria grow very slowly and it may take up to 20 years to develop signs of the infection.
  • The disease can affect the nerves, skin, eyes, and lining of the nose (nasal mucosa); the bacteria attack the nerves, which can become swollen under the skin; this can cause the affected areas to lose the ability to sense touch and pain, which can lead to injuries, like cuts and burns.
  • Leprosy can be considered two connected diseases that primarily affect superficial tissues, especially the skin and peripheral nerves.
  • In the 1990s, the World Health Organization (WHO) launched a campaign to eliminate leprosy as a public health problem by 2000; elimination, as defined by the WHO, was defined as a reduction of patients with leprosy requiring multidrug therapy to fewer than 1 per 10,000 population.
  • As of 2014, none of the 122 countries where leprosy was endemic in 1985 still have prevalence rates of greater than 1 per 10,000 population.

Pathophysiology

Leprosy can manifest in different forms, depending on the host’s response to the organism.

Multibacillary leprosy patient has multiple poorly defined reddish skin lesions, loss of eyebrows, nose collapse and development of ear nodules. Image via: American leprosy mission
  • Individuals who have a vigorous cellular immune response to M leprae have the tuberculoid form of the disease that usually involves the skin and peripheral nerves.
  • This form of the disease is also referred to as paucibacillary leprosy because of the low number of bacteria in the skin lesions (ie, < 5 skin lesions, with absence of organisms on smear).
  • Results of skin tests with antigen from killed organisms are positive in these individuals.
  • Individuals with minimal cellular immune response have the lepromatous form of the disease, which is characterized by extensive skin involvement.
  • The organism grows best at 27-30°C; therefore, skin lesions tend to develop in the cooler areas of the body, with sparing of the groin, axilla, and scalp.
  • This form of the disease is also referred to as multibacillary leprosy because of the large number of bacteria found in the lesions (ie, >6 lesions, with possible visualization of bacilli on smear).
  • Results of skin tests with antigen from killed organisms are nonreactive.
  • Patients may also present with features of both categories; however, over time, they usually evolve to one or the other (indeterminate or borderline leprosy).

Classification

Leprosy has 2 classification schemas: the 5-category Ridley-Jopling system and the simpler and more commonly used WHO standard.

  • Ridley-Jopling. Depending on the host response to the organism, leprosy can manifest clinically along a spectrum bounded by the tuberculoid and lepromatous forms of the disease; most patients fall into the intermediate classifications, which include borderline tuberculoid leprosy, midborderline leprosy, and borderline lepromatous leprosy; the Ridley-Jopling system is used globally and forms the basis of clinical studies of leprosy; it may also be more useful in guiding treatment regimens and assessing risk of acute complications.
  • WHO standard. According to the WHO, in an endemic area, an individual is considered to have leprosy if he or she shows either of the two following signs: a skin lesion consistent with leprosy and definite sensory loss, with or without thickened nerves, and positive skin smears.

Etiology

Mycobacterium leprae is the causative agent associated with leprosy, which has been recognized as an infectious disease for the last 2 millennia.

  • Transmission. The route of transmission has not been definitively established, although human-to-human aerosol spread of nasal secretions is thought to be the most likely mode of transmission in most cases.
  • Armadillos. In the southern United States, some armadillos are naturally infected with the bacteria that cause Hansen’s disease in people and it may be possible that they can spread it to people; however, the risk is very low and most people who come into contact with armadillos are unlikely to get Hansen’s disease.
  • Prolonged contact. Prolonged, close contact with someone with untreated leprosy over many months is needed to catch the disease.
  • You cannot get leprosy from a casual contact with a person who has Hansen’s disease, like shaking hands or hugging, sitting next to each other on the bus, sitting together at a meal.
  • Hansen’s disease is also not passed on from a mother to her unborn baby during pregnancy and it is also not spread through sexual contact.

Statistics and Incidences

In the U.S., Hansen’s disease is rare. Around the world, as many as 2 million people are permanently disabled as a result of Hansen’s disease.

  • India reported 127,326 new cases, accounting for 60% of the global new leprosy cases; Brazil, reported 26,395 new cases, representing 13% of the global new cases; and Indonesia reported 17,202 new cases, 8% of the global case load.
  • Eleven countries reported between 1000 and 10,000 cases: from Africa, the Democratic Republic of Congo, Ethiopia, Madagascar, Mozambique, Nigeria and United Republic of Tanzania; from Southeast Asia, Bangladesh, Myanmar, Nepal and Sri Lanka; and from Western Pacific, the Philippines.
  • Collectively, these countries reported 19,069 new cases, 14% of all new cases globally.
  • The remaining 10,286 new cases (5%) were reported by 92 countries.
  • Leprosy is rarely fatal, and the primary consequence of infection is nerve impairment and debilitating sequelae; according to one study, 33-56% of newly diagnosed patients already displayed signs of impaired nerve function.
  • Leprosy is generally more common in males than in females, with a male-to-female ratio of 2:1.
  • Leprosy can occur at any age, but, in developing countries, the age-specific incidence of leprosy peaks in children younger than 10 years, who account for 20% of leprosy cases.

Clinical Manifestations

Symptoms mainly affect the skin, nerves, and mucous membranes (the soft, moist areas just inside the body’s openings).

If left untreated, small muscles in the hand may be paralyzed resulting in the curling of the fingers and thumb. Image via: Omar Havana/Getty images
  • Skin symptoms. The disease can cause skin symptoms such as discolored patches of skin, usually flat, that may be numb and look faded (lighter than the skin around); growths (nodules) on the skin; thick, stiff or dry skin; painless ulcers on the soles of feet; painless swelling or lumps on the face or earlobes; and loss of eyebrows or eyelashes.
  • Nerve damage. Symptoms caused by damage to the nerves are numbness of affected areas of the skin, muscle weakness or paralysis (especially in the hands and feet), enlarged nerves (especially those around the elbow and knee and in the sides of the neck), and eye problems that may lead to blindness (when facial nerves are affected).
  • Damaged mucous membranes. Symptoms caused by the disease in the mucous membranes are a stuffy nose and nosebleeds.
  • Advanced leprosy. If left untreated, the signs of advanced leprosy can include paralysis and crippling of hands and feet, shortening of toes and fingers due to reabsorption, chronic non-healing ulcers on the bottoms of the feet, blindness, loss of eyebrows, and nose disfigurement.

Assessment and Diagnostic Findings

Hansen’s disease is diagnosed based on clinical presentation and the diagnosis is confirmed by skin or nerve biopsy and acid-fast staining.

Skin biopsy is done in diagnosing and classifying leprosy. Image by: Margreet Hogeweg
  • Skin and nerve biopsies. Biopsies are needed to definitively confirm a diagnosis of Hansen’s disease and to classify the disease, and slit skin smear may also be helpful in diagnosing those with the multibacillary disease.
  • Acid-fast staining. The Ziehl-Neelson method using 5% sulphuric acid as decolorizing agent is used; the presence of acid-fast bacilli confirms the diagnosis of Hansen’s disease.

Medical Management for Leprosy

Hansen’s disease is treated with multidrug therapy (MDT) using a combination of antibiotics depending on the form of the disease.

  • Medical care. The WHO recently recommended single-dose treatment with rifampin, minocycline, or ofloxacin in patients with paucibacillary leprosy who have a single skin lesion; however, the WHO still recommends the use of the long-term multidrug regimens whenever possible because they have been found to be more efficacious.
  • Surgical care. The goals of surgical treatment in patients with leprosy are to prevent further deterioration, to improve motor function, and, in some cases, to improve sensation; these may include neural surgery, reconstruction, and functional restoration, eye procedures, and cosmetic surgery.

Pharmacologic Management

The goals of pharmacotherapy are to eliminate the infection, to prevent complications, to halt its further transmission and spread, and to reduce morbidity.

  • Antibiotics. Paucibacillary form – 2 antibiotics are used at the same time, daily dapsone and rifampicin once per month
  • Multibacillary form – daily clofazimine is added to rifampicin and dapsone.

Nursing Management for Leprosy

Nursing care for a patient with leprosy include the following:

Nursing Assessment

Assessment of a patient with leprosy include:

  • History. Leprosy should be considered in anyone who has lived in the tropics or who has traveled for prolonged periods to endemic areas.
  • Physical exam. The cardinal signs of leprosy include hypoesthesia, skin lesions, and peripheral neuropathy; the first physical signs of leprosy are usually cutaneous; the subtype of leprosy often determines the degree of skin involvement.

Nursing Diagnosis

Based on the assessment data, the common nursing diagnosis for a patient with leprosy are:

  • Impaired skin and tissue integrity related to infection by M leprae and loss of skin sensitivity.
  • Disturbed body image related to crippling of hands and feet, shortening of fingers and toes, and nose disfigurement.
  • Impaired physical mobility related to crippling and paralysis.
  • Risk for injury related to damage on the sensory nerves.
  • Situational low self-esteem related to stigma and prejudice about the disease.

Nursing Care Planning and Goals

The major nursing care planning goals for a patient with leprosy include the following:

  • Patient demonstrates understanding of plan to heal tissue and prevent injury.
  • Patient describes measures to protect and heal the tissue, including wound care.
  • Patient incorporates changes into self-concept without negating self-esteem.
  • Patient verbalizes acceptance of self in situation.
  • Patient performs physical activity independently or within limits of disease.
  • Patient remains free of injuries.
  • Patient verbalizes positive self-acceptance.

Nursing Interventions

Nursing interventions for a patient with leprosy include the following:

  • Improve skin and tissue integrity. Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection; provide tissue care as needed; instruct patient to avoid rubbing and scratching; provide gloves or clip the nails if necessary; and administer antibiotics as ordered.
  • Acceptance of body image. Acknowledge and accept expression of feelings of frustration, dependency, anger, grief, and hostility; support verbalization of positive or negative feelings about the actual or perceived loss; assist the patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities; give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals; and support the patient in identifying ways of coping that have been beneficial in the past.
  • Assist in mobility. Present a safe environment: bed rails up, bed in down position, important items close by; let the patient accomplish tasks at his or her own pace; do not hurry the patient; encourage independent activity as able and safe; provide the patient of rest periods in between activities; and set goals with patient or Significant Other for cooperation in activities or exercise and position changes.
  • Prevent injury. Eliminate or drop all possible hazards in the room such as razors, medications, and matches; avoid extreme hot and cold around patients at risk for injury (e.g., heating pads, hot water for baths/showers); and for patients with visual impairment, educate him or caregiver to label with bright colors such as yellow or red significant places in environment that must be easily located (e.g., stair edges, stove controls, light switches).
  • Encourage positive self-esteem. Present an environment favorable to the expression of feelings; support the patient in his or her attempts to secure autonomy, reality, positive self-esteem, sense of capability, and problem-solving; educate the patient to join in activities anticipated to result in healthy self-esteem; and educate the patient about the harmful effects of negative self-talk.

Evaluation

Evaluation of nursing care for patients with leprosy includes meeting the following goals:

  • Patient demonstrated understanding of plan to heal tissue and prevent injury.
  • Patient described measures to protect and heal the tissue, including wound care.
  • Patient incorporated changes into self-concept without negating self-esteem.
  • Patient verbalized acceptance of self in situation.
  • Patient performed physical activity independently or within limits of disease.
  • Patient remained free of injuries.
    Patient verbalized positive self-acceptance.

Documentation Guidelines

Documentation in a patient with leprosy include:

  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward the desired outcome.

Summary

Here are some of the most important points about leprosy:

  • Hansen’s disease (also known as leprosy) is an infection caused by slow-growing bacteria called Mycobacterium leprae.
  • The disease can affect the nerves, skin, eyes, and lining of the nose (nasal mucosa); the bacteria attack the nerves, which can become swollen under the skin; this can cause the affected areas to lose the ability to sense touch and pain, which can lead to injuries, like cuts and burns.
  • Individuals who have a vigorous cellular immune response to M leprae have the tuberculoid form of the disease that usually involves the skin and peripheral nerves, also referred to as paucibacillary leprosy.
  • Individuals with minimal cellular immune response have the lepromatous form of the disease, which is characterized by extensive skin involvement, also known as multibacillary leprosy.
  • Leprosy has 2 classification schemas: the 5-category Ridley-Jopling system and the simpler and more commonly used WHO standard.
  • The route of transmission has not been definitively established, although human-to-human aerosol spread of nasal secretions is thought to be the most likely mode of transmission in most cases.
  • Around the world, as many as 2 million people are permanently disabled as a result of Hansen’s disease.
  • Symptoms mainly affect the skin, nerves, and mucous membranes (the soft, moist areas just inside the body’s openings).
  • Hansen’s disease is diagnosed based on clinical presentation and the diagnosis is confirmed by skin or nerve biopsy and acid fast staining.
  • Hansen’s disease is treated with multidrug therapy (MDT) using a combination of antibiotics depending on the form of the disease.

Practice Quiz: Leprosy (Hansen’s Disease)

Nursing practice questions for Leprosy (Hansen’s Disease). For more practice questions, visit our NCLEX practice questions page.

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1. Diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of leprosy?

A. Macular lesions.
B. Inability to close eyelids.
C. Thickened painful nerves.
D. Sinking of the nose bridge.

1. Answer: C. Thickened painful nerves.

  • Option C: The lesion of leprosy is not macular. It is characterized by a change in skin color (either reddish or whitish) and loss of sensation, sweating and hair growth over the lesion.
  • Options B & D: Inability to close the eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms.

2. Which of the following clients should be classified as a case of mutibacillary leprosy?

A. 3 skin lesions, negative slit skin smear.
B. 3 skin lesions, positive slit skin smear.
C. 5 skin lesions, negative slit skin smear.
D. 5 skin lesions, positive slit skin smear.

2. Answer: D. 5 skin lesions, positive slit skin smear.

  • Option D: A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin lesions.

3. Nurse JV is performing wound care. Which of the following practices violates surgical asepsis?

A. Holding sterile objects above the waist.
B. Considering a 1″ edge around the sterile field as being contaminated.
C. Pouring solution onto a sterile field cloth.
D. Opening the outermost flap of a sterile package away from the body.

3. Answer: C. Pouring solution onto a sterile field cloth.

  • Option C: Pouring solution onto a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action.
  • Options A, B, D: The other options are practices that help ensure surgical asepsis.

4. Nurse Catherine is changing a dressing and providing wound care. Which activity should she perform first?

A. Assess the drainage in the dressing.
B. Slowly remove the soiled dressing.
C. Wash hands thoroughly.
D. Put on latex gloves.

4. Answer: C. Wash hands thoroughly.

  • Option C: When caring for a client, the nurse must first wash her hands.
  • Options A, B, D: Putting on gloves, removing the dressing, and observing the drainage are all parts of performing a dressing change after hand washing is completed.

5. A male client schedule for a skin biopsy is concerned and asks the nurse how painful the procedure is. The appropriate response by the nurse is:

A. “There is no pain associated with this procedure”
B. “The local anesthetic may cause a burning or stinging sensation”
C. A preoperative medication will be given so you will be sleeping and will not feel any pain”
D. “There is some pain, but the physician will prescribe an opioid analgesic following the procedure”

5. Answer: B. “The local anesthetic may cause a burning or stinging sensation”

  • Option B: Depending on the size and location of the lesion, a biopsy is usually a quick and almost painless procedure. The most common source of pain is the initial local anesthetic, which can produce a burning or stinging sensation.
  • Option C: Preoperative medication is not necessary for this procedure.

References

  • Smith, D.S. , MD, MSc, DTM&H (2018, Aug 24). Leprosy. Retrieved from https://emedicine.medscape.com/article/220455-overview
  • Centers for Disease Control and Prevention (2017, Feb 10). Hansen’s Disease (Leprosy). Retrieved from https://www.cdc.gov/leprosy/index.html

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