›Consider if nerve abscess identified or if medical therapy fails after adequate trial
›Perineural corticosteroid injection — emerging option for isolated nerve trunk neuritis under ultrasound guidance
›Mild ENL — skin-only involvement, no fever
›NSAIDs — ibuprofen 400–600 mg three times daily with food
›Short-term use; monitor renal function in glomerulonephritis risk
›Low-dose prednisolone 20–30 mg/day if NSAID insufficient
›Moderate to severe ENL — first-line
›Thalidomide — treatment of choice for moderate-severe ENL
›100–300 mg/day orally (up to 400 mg/day for severe cases)
›Taper by 50 mg every 2–4 weeks once symptoms controlled
›Low-dose regimens 25–150 mg/day show comparable efficacy in real-world studies
›REMS program mandatory — System for Thalidomide Education and Prescribing Safety (STEPS)
›Absolute contraindication in pregnancy — Category X teratogen (thalidomide embryopathy)
›Monthly pregnancy testing required
›Two forms of contraception required for women of childbearing potential
›Thalidomide-associated peripheral neuropathy — dose-dependent cumulative risk
›Baseline nerve conduction study and monitoring during treatment
›Sedation, constipation, DVT/PE — additional monitoring parameters
›Corticosteroids added to thalidomide if neuritis co-present
›Prednisolone 40–60 mg/day as above, tapered over 20+ weeks
›Chronic and recurrent ENL
›Clofazimine 300 mg/day for 3 months then 200 mg/day for 3 months, then 100 mg/day maintenance
›Superior to thalidomide for preventing ENL recurrence
›Already component of MB-MDT but dose escalated during reactions
›Skin pigmentation (red-brown) is expected and reversible
›ECG monitoring at doses >100 mg/day — rare QT prolongation
›Methotrexate 10–15 mg weekly — steroid-sparing in chronic ENL
›Pentoxifylline 400 mg three times daily — adjunct anti-TNF mechanism; limited evidence
Lucio's phenomenon treatment
›No standardized protocol exists
›Antimicrobial therapy
›Broad-spectrum antibiotics for superimposed bacterial infection or sepsis
›Empiric coverage tailored to local resistance patterns and wound flora
›Continue anti-leprosy MDT
›Anti-inflammatory therapy
›Corticosteroids at moderate dose — prednisolone 40 mg/day, tapered slowly
›Thalidomide data limited in Lucio's
›Anticoagulation
›Heparin or LMWH — thrombotic vasculopathy component
›No RCT data; case series support use
›Monitor for bleeding given ulcerated wounds
›Wound care
›Wound care team involvement
›Debridement if necrotic tissue present
›Split-thickness skin grafting for large ulcers once stabilized
Supportive care — all reactions
›Nutritional support
›Adequate caloric and protein intake during catabolic inflammatory states
›Calcium and vitamin D supplementation for all on corticosteroids
›Dietary counseling for glucose control if steroid-induced hyperglycemia
›Wound and limb care
›Protective footwear for plantar anesthesia — prevent Charcot foot and trophic ulcers
›Physiotherapy — hand and foot exercises to preserve function and prevent contracture
›Splinting for acute claw hand or foot drop
›Infection prevention during immunosuppression
›TB prophylaxis if IGRA positive before steroids
›Pneumocystis prophylaxis with trimethoprim-sulfamethoxazole 480 mg/day if on high-dose prolonged steroids
›Avoid live vaccines during immunosuppression