Short-term trial of clofazimine in previously untreated lepromatous leprosy

Forty-five previously untreated lepromatous leprosy patients were allocated randomly to three groups and treated, respectively, with Regimen A, standard dosage of clofazimine (CLO) in multidrug therapy (MDT) regimen; Regimen B, CLO 600 mg once every 4 weeks; and Regimen C, CLO 1200 mg once every 4 weeks. The duration of the trial was 24 weeks. By the end of the trial, although a few patients in each group did not improve at all clinically, the majority of patients showed clinical amelioration but the responses were slow. While the mean morphological index dropped to the baseline after 24 weeks of treatment, the mean bacterial index did not change significantly. About 80% of the patients in each group remained nasal-smear positive at the end of the trial, but the bacterial loads steadily declined. No significant difference has been detected in these parameters among the three groups. The patients tolerated the regimens very well and the side effects were mild. The results of serial mouse foot pad inoculation demonstrated that the positivity rates of multiplication of Mycobacterium leprae in mice and the proportions of viable organisms reduced gradually in all groups. Because the positivity rate at week 24 in Group C did not differ significantly from Group A, but was significantly smaller than that of Group B, we conclude that Regimen C was as active as Regimen A and could be applied for monthly supervised treatment along with rifampin; Regimen B is less effective and should not be used for the treatment of leprosy.

Critical comments on the treatment of leprosy and other mycobacterial infections with clofazimine

The usefulness of clofazimine (CLO, CAS 2030-63-9) in the treatment of mycobacterial infections with special emphasis on treatment of leprosy is critically discussed. Skin discolouration which decreases compliance, placenta passage, excretion in mother's milk which endanger the embryo or baby respectively, saturation kinetics in absorption and difficulties to determine free drug concentration are severe problems. The observed antagonism in the combination of CLO with other drugs, especially with dapsone, is another argument against its application in the therapy of mycobacterial infections. In Germany CLO has not been approved by the Bundesgesundheitsamt.

Dapsone syndrome in Vanuatu: a high incidence during multidrug treatment (MDT) of leprosy

Side-effects of leprosy treatment with dapsone are said to be uncommon, with drug allergy occurring in only one of every several hundred patients treated with dapsone. The dapsone or sulphone syndrome (DDS) has been recognized since the earliest days of sulphone therapy but until recently its incidence had been decreasing. In Vanuatu, during the years 1988-1991, nine leprosy patients have developed the dapsone syndrome, four of whom have died. During the last 4 years only 37 patients were started on treatment, which is an incidence of the dapsone syndrome of 24% with a fatality rate of 11%. All the patients were being given multi-drug treatment (MDT) of daily dapsone (100 mg) and clofazimine (50 mg) and monthly rifampicin (600 mg) and clofazimine (300 mg). There has been speculation that the increased incidence of what was previously described as a rare reaction is due to the use of MDT, and the reasons for this are discussed. We feel the increase in the number of reactions in Vanuatu since starting MDT is probably due to the high starting dose of 100 mg of dapsone, possibly enhanced by the combination with clofazimine and rifampicin and a genetic susceptibility of the Melanesian population.

New histopathologic findings in drug eruptions

Several new findings associated with hyperpigmentation have been reported in the past decade, the most notable being amiodarone-induced hyperpigmentation, which was shown to demonstrate both a lymphocytic dermatitis as well as yellowish brown granules that can be found within several cell types. The nature of this material has not been elucidated, although the drug or one of its metabolites composes at least a portion of the granules. The nature of the clofazimine-induced hyperpigmentation was shown to be caused by the accumulation of a ceroid lipofuscin within lipid-laden macrophages. Several chemotherapy-induced clinical and histologic changes have been reported in the past decade because of new chemotherapeutic drugs, better recognition of histologic reaction patterns, and the use of higher dosages by oncologists. A unique dermatitis, cutaneous eruption of lymphocyte recovery--although not directly due to use of chemotherapeutic agents--occurs after the return of immunocompetent lymphocytes in the peripheral circulation and skin, producing a maculopapular eruption that demonstrates a nonspecific superficial perivascular dermatitis on biopsy. Another clinically specific reaction, chemotherapy-induced acral erythema, demonstrates a nonspecific histologic pattern characterized by an interface dermatitis. Specific histologic patterns were reported for reactions following use of etoposide--starburst cells--and of busulfan--large atypical keratinocytes. There have been reports of new reactions due to chemotherapeutic agents involving sweat glands: neutrophilic eccrine hidradenitis, characterized by neutrophils and necrosis; and syringosquamous metaplasia, a histologic reaction of the sweat duct characterized by squamous metaplasia. New inflammatory reaction patterns include drug-induced generalized pustular toxic erythema, which histologically shows subcorneal pustules and occasional eosinophils. Cephalosporins were reported to produce a syndrome that clinically and histologically resembles pemphigus. Naproxen is reported to produce a clinical and histologic reaction similar to porphyria cutanea tarda. Quinine and piroxicam both induce a photosensitive dermatitis that histologically shows a nonspecific spongiotic dermatitis. A histologically unique reaction pattern manifesting as a lichenoid giant cell dermatitis may be produced by use of either methyldopa or chlorothiazide. Both phenytoin and carbamazepine produce a dermatitis that histologically imitates mycosis fungoides. Finally, phytonadione injections may produce a clinical and histologic reaction that resembles morphea.

Controlled trial of antimycobacterial therapy in Crohn's disease. Clofazimine versus placebo

In order to study the effect of clofazimine, a powerful antimycobacterial and antiinflammatory agent, 49 patients with active Crohn's disease were randomized to either corticosteroids plus clofazimine 100 mg daily (N = 25) or to steroids and matching placebo (N = 24). A total of 28 patients (58%) went into disease remission (clofazimine 16, placebo 12; P = NS) with a fall in disease activity score from 10.5 +/- 4.4 to 3.3 +/- 3.5. Patients were treated for a further eight months with clofazimine or placebo and 18 of 28 maintained their remission and completed the study (clofazimine 12, placebo 6; P = NS). Side effects were minor and consisted of skin rash and increased pigmentation. Clofazimine as a solitary antimycobacterial agent appears ineffective in inducing remission in Crohn's disease but may have a role in either disease maintenance or combination chemotherapy.

Orange/black discolouration of the bowel (at laparotomy) due to clofazimine

Clofazimine, a commonly used anti-lepromatous drug, is now being prescribed for the treatment of pyoderma gangrenosum, a complication of inflammatory bowel disease. This drug can cause an obstructive exacerbation of Crohn's disease. Surgeons should be aware of the orange/black discolouration of the bowel, which may mimic ischaemia macroscopically. A case, the first reported in Australia, is described and the literature discussed.

Skin pigmentation from clofazimine therapy in leprosy patients: a reappraisal

Skin biopsy specimens from two lepromatous leprosy patients with dark brown pigmentation who were receiving long-term clofazimine therapy were studied. Ceroid-lipofuscin pigment was demonstrated inside macrophages that contained numerous phagolysosomes. These contained lipids and clofazimine that appeared as electron-lucent vacuoles and a lipofuscin pigment that was electron dense, granular, and lamellated. Although the presence of the drug in tissues contributed to the skin pigmentation, the main cause was a drug-induced, reversible ceroid lipofuscinosis.

Effect of clofazimine on eye in multibacillary leprosy

Seventy-six patients of multibacillary leprosy received clofazimine as part of multidrug therapy (MDT) for periods ranging between 6 and 24 months. Complete ocular examination including slit lamp microscopy and examination of tears was carried out in all these patients. Reddish brown conjunctival and corneal pigmentation was seen in 46% and 53% of the patients respectively. Clofazimine crystals in tears were found in 32% of the patients. Apart from this no other eye changes or symptoms attributable to clofazimine were observed.

Clofazimine induced nail changes

Two cases of lepromatous leprosy with erythema nodosum leprosum who were on high doses of clofazimine, showed discoloration of nail plate, subungual hyperkeratosis and onycholysis. These nail changes gradually disappeared when the dose of clofazimine was reduced.

Ultrastructural findings in oral hyperpigmentation of HIV-infected patients

Oral hyperpigmentation has been observed in six HIV-infected patients, in two of whom systemic medication (ketokonazole, clofazimine) was supposed to be etiologically involved. Histologically, pigment was found in epithelial basal cells and particularly in subepithelial connective tissue. Ultrastructurally, the presence of premature melanosomes in subepithelial keratinocytes was of interest. Stimulation of melanocytes during HIV infection may occur in association with immunopathologic changes in the oral mucosa.

Clofazimin in the treatment of scleroma

Scleroma is a chronic progressive granulomatous disease predominantly affecting the mucous membrane of the upper respiratory tract, endemic in temperate and tropical zone countries including Egypt. Many patients in early stages respond to medical treatment while others do not. In these patients an antileprotic agent Clofazimin (Lamprene) was tried in 76 patients and the therapeutic results are very promising, especially for the early stages of the disease.

Short-term multidrug therapy in multibacillary leprosy--review of 80 cases in two provinces of China (1983-1988)

Thirty-three active multibacillary patients from nine counties of Weifang Prefecture, Shandong Province, and 47 active cases from Menla County, Yunnan Province, People's Republic of China, were treated with 24 and 27 months of multidrug therapy (MDT), respectively, in 1983. Clinical assessments, smears, and histopathologic examinations were carried out independently by study teams from the Institutes of Dermatology of these two provinces. Reexaminations at 12-14 months and at termination of therapy showed marked improvement, and there was continued improvement at 12-18 and 33 months on follow up. Conversion of the bacterial index to negativity was 0/33, 5/47 for the patients from Shandong and Yunnan provinces, respectively, at the end of MDT and 2/33 at 12 months' and 17/47 at 18 months' follow up, which increased to 21/33 and 26/44 at 33 months' follow up. Regression of specific infiltration was about 21%-100% after 24-27 months of MDT; further regression to 95%-100% occurred at 33 months' follow up.

Clinical trial with clofazimine for treating erythema dyschromicum perstans. Evaluation of cell-mediated immunity

Eight patients were studied to determine the possible use of clofazimine for treating erythema dyschromicum perstans (EDP). The T-helper/T-suppressor cytotoxic ratio (CD-4/CD-8) and the in vitro lymphoproliferative response on stimulation with phytohemaglutin (PHA) and concanavalin A (Con A) were determined in peripheral blood before and after treatment. Of the eight patients studied, seven had excellent to good responses, whereas only one had a marginal response. The immunologic evaluation before and after treatment showed a significant change in the CD-4/CD-8 ratio, a decrease of the response to PHA, and no change in the response to Con A. The results obtained show that clofazimine is useful for treating this nosologic entity because of its cosmetic effect, and also because it induces changes in cell-mediated response, which could be very important therapeutically.

Oral hyperpigmentation in HIV-infected patients

Six cases of oral hyperpigmentation in HIV-infected patients are reported. While in two patients the lesions could be related to systemic clofazimine or ketoconazole therapy, in the other patients the cause remained unknown. Clinically, the pigmentations were characterized by a sudden onset and the appearance of well-defined, brown-black macules in the buccal mucosa, the gingiva, the hard palate, or the lateral borders of the tongue. In one patient, longitudinal hyperpigmented striae were observed on all fingernails and toenails. Histologically, hyperpigmentations associated with systemic medication revealed accumulation of melanin in phagocytes and extracellularly within the connective tissue. In those lesions with unknown cause, melanin was restricted to keratinocytes of the basal cell layer or to extracellular foci in the lamina propria. The clinical and histologic findings, as well as differential diagnosis, are discussed.

Polychromatic corneal and conjunctival crystals secondary to clofazimine therapy in a leper

A 67-year-old man had a diagnosis of dapsone-resistant lepromatous leprosy. He received clofazimine (Lamprene) at a dosage of 100 mg twice daily. After 3 years of therapy, results of slit-lamp examination disclosed myriad polychromatic crystals diffusely involving the cornea and perilimbal conjunctiva of both eyes. Thick sections (1 micron) from a conjunctival biopsy showed numerous rectangular-to-rhomboidal crystals within stromal fibroblasts and macrophages. By electron microscopy, these cells contained elongated, membrane-bound, cleft-like spaces that corresponded to the sites where crystals had been present previously. Additionally, complex lipid inclusions were observed in mesenchymal cells as well as in endothelial cells and pericytes of blood vessels. The ocular side effects of clofazimine therapy are reviewed. Clofazimine-induced keratopathy should be included in the differential diagnosis of patients with polychromatic crystalline deposits in the corneas. To the best of the authors' knowledge, this complication of clofazimine therapy has not been described previously.

A study of dermatological conditions in leprosy in-patients

Three hundred and sixty six in-patients in a leprosy hospital were examined for other dermatological conditions. Eighty eight of them displayed ichthyosiform changes. A peculiar condition of a verrucous hyperkeratotic growth on the anterior aspect of ankle, not described previously, was observed in four patients. It was noted that 11 out of 12 patients with scabies did not have the classical lesions in web spaces of the hands.

Changing picture of leprosy in North Arcot District, Tamil Nadu after M.D.T

This paper discussed the effect in a 5 year period (1983-88) of MDT on the Leprosy situation in North Arcot District where MDT was started in 1983. The cases at the start of MDT were 68351 and 29511 cases were detected in the year period and the total case load was 97862. Out of this total case load 84810 cases were deleted by RFC, deaths or PL*. The causes for deletions are discussed in detail. The remaining case load at the end of the 5 year period is 13052 or 13.35% of the cases at start. The M.D.T. has definitely played a part in the drastic reduction of the case load since the major number of cases have been deleted as RFC due to cure of the disease and so the future planning of leprosy work when the case load becomes very low is also discussed.