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.