Received: 23 March 2016 | Revised: 21 June 2016 | Accepted: 26 July 2016

DOI 10.1111/dth.12414

THERAPEUTIC HOTLINE: SHORT PAPERS

Leprosy treatment during pregnancy and breastfeeding: A case

report and brief review of literature

Z. Ozturk1 | A. Tatliparmak2

1
Department of Clinical Pharmacology and
Toxicology, Ataturk Research Hospital, Izmir,
Turkey
2
Department of Dermatology, Fatih Medical
Park Hospital, Istanbul, Turkey
Correspondence
Zeynep Ozturk, MD Specialist for Medical
Pharmacology Department of Clinical
Pharmacology and Toxicology, Ataturk
Research Hospital, Izmir, Turkey.
Email: dr.zeyneb@hotmail.com
Abstract
Leprosy is a chronic disease which primarily aects the skin, mucous membranes and peripheral
nerves due to Mycobacterium leprae. It is now infrequent in Europe and is rarely reported during
pregnancy. Leprosy can be exacerbated during pregnancy, and without treatment it can perma-
nently damage the skin, nerves, limbs and eyes. Therefore, it is important to treat leprosy during
pregnancy. This article describes a patient with multibacillary lepromatous leprosy who was
treated with multidrug therapy during pregnancy and breastfeeding. The patient delivered a
healthy baby girl without perinatal complications, and the infants growth and development were
normal during the 1-year follow-up period. Multidrug therapy consisting of dapsone, rifampicine,
and clofazimine is highly eective for people with leprosy and considered safe, both for the
mother and the child. Antileprosy drugs are excreted into human milk but there is no report of
adverse eects except for skin discoloration of the infant due to clofazimine. Multidrug therapy
for leprosy patients should be continued unchanged during pregnancy and breastfeeding.

KEYWORDS
breastfeeding, leprosy, medication, pregnancy

1 | INTRODUCTION 2 | CASE REPORT

Leprosy, also known as Hansens disease, is an infectious disease
caused by Mycobacterium leprae. There is a wide spectrum of clinical
ndings depending on hosts cellular immunity: lepromatous type
which occurs in patients with depressed cell mediated immunity, tuber-
culoid type in patients with intact cell mediated immunity, indetermi-
nate type, and borderline type. The clinical ndings of leprosy involve
the skin and the nervous system (Kundakci & Erdem, 2008; Ramos-e-
Silva & Castro, 2008).
Leprosy during pregnancy has been rarely reported in Europe and
United States. Due to suppression of the cell mediated immunity in
pregnancy, especially in the third trimester, downgrading reactions may
occur. There is a down regulation of T helper 1 type response with
decreased production of interleukin 2. The decrease in cell mediated
immunity may also increase the risk of leprosy relapse (Lockwood &
Sinha, 1999). Early diagnosis is important, and medication can reduce
the risk of catching the disease for leprosy patients. This report
presents a case of multibacillary lepromatous leprosy and its treatment
during pregnancy and breastfeeding.
A 26-year-old multiparous woman with a known case of multibacillary
leprosy presented with unplanned pregnancy. Her pregnancy was dis-
covered in the ninth week, and she had been taking a multidrug ther-
apy (dapsone 100 mg/day, rifampicin 600 mg/month, clofazimine
50 mg/day and clofazimine 300 mg/month) for the past 8 months. She
had multiple, shiny, erythematous macules on the face, arms, and body.
Skin punch biopsy revealed subepidermal clear zone, numerous foamy
histiocytes throughout the dermis, dense cellularity, and few perivascu-
lar lymphocytes corresponding to lepromatous leprosy. The patient
was informed about the risks of drugs used in pregnancy. The treat-
ment was continued unchanged during pregnancy. A detailed fetal
ultrasonography was oered to scan the development of the fetus at
about 20 weeks.
In the 8th, 22nd, 28th weeks of pregnancy, prenatal sonographic
examinations revealed normal fetal growth and amniotic uid volume.
At 28 weeks pregnant, she was diagnosed with gestational diabetes.
Diabetes did not cause any symptoms during pregnancy, and it was
controlled with a reduced-calorie diet in a week. The patient delivered

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a healthy baby girl by vaginal birth in the 39th week of gestation with-
out perinatal complications. The baby was also healthy (APGAR 89,
3,300 g, 51 cm), and her growth and development were normal during
the 1-year follow-up period. The patient decided to breastfeed while
taking medications. Skin discoloration was observed in newborn due to
clofazimine during breastfeeding. After 3 months, she stopped breast-
feeding, and the infants skin changes were reversed. Informed consent
was taken from the patient for reporting this case.
3 | DISCUSSION
Leprosy can be exacerbated during pregnancy, and without treatment
it can permanently damage the skin, nerves, limbs and eyes. Therefore,
it is important to treat leprosy during pregnancy. For patients with mul-
tibacillary leprosy, treatment guidelines by the World Health Organiza-
tion (WHO) recommend multidrug therapy using rifampicin, dapsone,
and clofazimine. According to the WHO, these agents must never be
used alone as monotherapy for leprosy and must never be stopped
during pregnancy (WHO, 1998).
Rifampicin is used in the treatment of leprosy and tuberculosis and
can cross the placenta. There are more than 300 case reports on the
use of rifampicin during pregnancy, no increased risk of birth defects
can be concluded from this data (Khilnani, 2004). A very small amount
of drug (about 5% of the therapeutic dose) can be transferred to
human milk. No adverse eects in exposed neonates have been
reported, and rifampicin is considered compatible with breastfeeding
(Snider & Powell, 1984).
Dapsone (diaminodiphenylsulfone) has been used primarily in the
therapy of leprosy and dermatitis herpetiformis, occasionally in the
treatment of malaria, Pneumocystis carinii pneumonia, and in many
other dermatological disorders. Although no controlled studies have
been reported, several case reports have described successful pregnan-
cies in women who received dapsone during pregnancy. There are
some case reports of dapsone-induced hemolytic anemia in mothers
and their babies, whose symptoms resolved after discontinuing dap-
sone. The American Academy of Pediatrics classies dapsone as com-
patible with breastfeeding, although WHO considers dapsone during
breastfeeding not safe. Nearly 15% of the weight-related maternal
dosage of dapsone can enter human milk. Therefore, if the treatment is
absolutely necessary, it must be decided on an individual basis whether
breastfeeding should be limited (Schaefer, Peters, & Miller, 2007).
Clofazimine, another antileprosy drug, can cross the placenta and
cause skin discoloration in the fetus. There are only very few publica-
tions with a small number of cases regarding clofazimine during preg-
nancy and breastfeeding. In these cases (a total of 20 cases), there
were no congenital malformations, and all of the infants were appa-
rently normal except for three unexplained neonatal deaths due to pre-
maturity, gastroenteritis and other unknown reasons (Holdiness, 1989;
Lyde, 1997). Clofazimine can pass into the milk and the proportion
OZTURK AND TATLIPARMAK
transferred with the milk was estimated to be approximately 22% of
the maternal dose. Acute toxicity as a result of clofazimine in the milk
is unlikely. However, there have been reports that the use of clofazi-
mine during breastfeeding may increase skin discoloration in nursing
infants (Venkatesan, Mathur, Girdhar, & Girdhar, 1997).
4 | CONCLUSION
For pregnant woman and practitioners, treatment of leprosy in preg-
nancy can be complicated. Physical and neurological damage may be
irreversible even if cured. Multidrug therapy consisting of dapsone,
rifampin, and clofazimine is highly eective for people with leprosy and
considered safe, both for the mother and the child. Antileprosy drugs
are excreted into human milk but there is no report of adverse eects
except for skin discoloration of the infant due to clofazimine. There-
fore, multidrug therapy for leprosy patients should be continued
unchanged during pregnancy and breastfeeding.
CONFLIC T OF I NTE RE ST
The author declares that there are no conicts of interest.
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