DISCUSSION
Leprosy is classically characterized by hypo pigmented or erythematous
skin lesions with loss of sensation with or without peripheral nerve
thickening. 7
Along with increasing prevalence of Leprosy in the post elimination
era, various atypical presentations have been
recorded.8
The diagnosis of leprosy when it presents as acne vulgaris without the
telltale features in skin or nerve involvement is often difficult and
remains a diagnostic challenge often inundating physicians. It is
because in the post elimination era leprosy as a differential doesn’t
strike physicians easily due to significantly decreased incidence.9 Our patient presented with acne-like lesions
(maculopapularlesions, pustules and nodules) on the face which later
progressed to different parts of the body. Though papules have been a
common presentation, progression of lesions to pustules and nodules has
rarely been witnessed.
Leprosy rarely presents with singular manifestation of skin lesions
only. 10 The skin lesions when present are in
the form of papules but rarely comedones, papules progressing to
nodules.11
Acne vulgaris is common in teenagers, and incidence has been noted in
every 9 out of 10 adolescents. 12 T he
common presentation being comedones, papules, nodules on face, back
and patient being a young female with above features in absence of any
other appreciable systemic features acne vulgaris was considered as
diagnosis of inclusion .Skin biopsy of acne vulgaris presents with
dilated follicle with keratin plug, in advanced cases dilated follicle
with open comedone may be seen, with signs of inflammation, presence of
bacteria when follicle ruptures along with fibrosis and scarring.13
Most adolescents experiencing facial acne have responded to Local
application of Retinoic Acid Gel as demonstrated by PERFECT trail
however our patient did not respond.14 Thus her workup was performed to
rule out other dermatological conditions causes like Cutaneous
Tuberculosis, SLE, Fungal or Bacterial Infections. This was done because
of the fact that in the clinical setting, skin lesion of leprosy is
often misdiagnosed as other dermatological conditions like erythematous
plaque seen on leprosy may be labeled as tinea, psoriasis, lupus
vulgaris etc. and hypopigmented patches are labeled as pityriasis alba,
pityriasisversicolor, and vitiligo etc. 15
The pathogenesis behind such skin manifestations would be generation of
inflammatory mediators like prostaglandins which were not suppressed
with treatment in line with Acne vulgaris hence the patient didn’t show
improvement. 8
In the reported case, some aspects drew our attention. Our patient was a
young female with macules and comedones on the skin of face, without
recognizable signs of neuropathy, which was non- contagious as family
members weren’t affected by disease, and although she had prolonged
disease period; with treatment disease was managed without irreversible
disability involving eyes, hands and feet due to neuropathy.
Close contact with leprosy patients in elderly and age group 5-15 years,
immunosuppressed individuals should be ruled out in skin lesions
persisting for long periods, resistant to routine treatment even when
neurological symptoms are lacking, skin biopsy must be obtained.