A patient with borderline tuberculoid leprosy develops an upgrading reaction with marked oedema and tenderness of existing plaques and acute neuritis of the great auricular nerve. Which drug forms the backbone of management, and why is thalidomide not used here?

• A Oral prednisolone in a tapering course, because thalidomide is ineffective in type 1 reactions ✓
• B Clofazimine, because steroids worsen type 1 reactions
• C Thalidomide, because it suppresses TNF-alpha better than any other agent
• D Increasing the frequency of rifampicin doses, because the reaction signals inadequate chemotherapy

Explanation

Type 1 reversal reactions reflect a sudden rise in cell-mediated immunity against M. leprae antigens and are managed with systemic corticosteroids, typically oral prednisolone started at 40 to 60 mg daily and tapered over weeks to months, especially when nerves are threatened. Thalidomide, though excellent for ENL, does not work for reversal reactions. Rifampicin dosing need not change, since reactions occur commonly during effective therapy due to antigen release and immune reconstitution.

Reference: IAL Textbook of Leprosy, 3rd ed.

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