|
CME ARTICLE |
|
| Year : 2009 | Volume
: 54
| Issue : 3 | Page : 206-210 |
|
| Immune zones in leprosy |
|
|
TS Rajashekar, Gurcharan Singh, L Chandra Naik
Department of Dermatology, Sri Devaraj Urs Medical College, Tamaka, Kolar - 563 101, Karnataka, India
| Date of Web Publication | 10-Sep-2009 |
Correspondence Address:
T S Rajashekar
Department of Dermatology, R.L. Jalappa Hospital & Research Centre, Tamaka, Kolar - 563 101, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-5154.55626
|
|
 Abstract | | |
Leprosy affects mainly those areas of skin which have a relatively lower temperature and are more exposed to trauma. Certain zones like scalp, palms and soles, genitalia, groins, axillae, eyelids, transverse band of skin over lumboscaral area, midline of back and perineum have been described to be immune to the development of lesions in leprosy. But clinical, histological and bacteriological evidence of involvement of these so called immune zones though infrequent have been documented. Hence, these immune zones should be termed as relatively immune, rather than absolutely immune zones of leprosy.
Keywords: High local temperature, immune zones, relatively immune
How to cite this article:
Rajashekar T S, Singh G, Naik L C. Immune zones in leprosy. Indian J Dermatol 2009;54:206-10 |
Leprosy affects mainly those areas of the skin, which have a relatively lower temperature and are more exposed to trauma. Thus, leprosy lesions are found commonly over the face, knees, elbows, gluteal region, dorsal aspects of the extremities, and trunk. [1],[2] Yet, certain zones such as scalp, palms and soles, genitalia, groins, axillae, eyelids, transverse band of skin over lumboscaral area, and midline of back and perineum have been described to be immune to the development of lesions in leprosy. [3],[4],[5] The reason for sparing of these zones has been attributed to the relatively high local temperature. [2],[3],[6] However, clinical, histological, and bacteriological evidence of involvement of these so-called immune zones though infrequent has been documented and briefly reviewed in the succeeding text.
| Scalp as an Immune Zone in Leprosy | |  |
Scalp is considered to be one of the immune zones in leprosy in addition to other sites mentioned. [7],[8],[9],[10],[11],[12],[13],[14] However, Muir (1938) states that "lesions on the scalp are quite common though the denseness of the hair and the covering provided by it renders the lesions on the scalp less conspicuous". [14]
Scalp involvement in leprosy can be classified into:
- Leprotic alopecia;
- Involvement of the bald area of the scalp;
- Extension of anesthesia from neighboring lesion;
- Apparently normal skin showing AFB in histopathological sections or slit skin smear examination;
- Involvement of hairy area of scalp. [7]
Oteig and Pinegro (1960) classified leprotic alopecia into,
- Diffuse alopecia;
- Regional alopecia localized to temple;
- Circumscribed alopecia;
- Mitsuda's type;
- Wig-type. [7],[15]
Leprotic alopecia is more common in the temporal area of scalp, but the area overlying the course of the temporal artery is spared. [16],[17],[18] Leprotic alopecia, which is seen in Japanese patients suffering from lepromatous leprosy, has been well illustrated by Mitsuda. [18] Cochrane, referring to the rarity of this condition observed that in certain races particularly the Mongolian and occasionally European, a leprous alopecia is sometimes seen. Scalp involvement is also rare in African patients but never as far as known among the Indians. [3],[8],[10]
Involvement of hairy scalp is considered to be very rare, the scanty reports of scalp involvement in leprosy have been mostly on the bald areas of scalp. [9],[19],[20] Hairy scalp has higher skin temperature than the other parts by approximately 5°C. [2],[6] It is well known that M. leprae has more predilection for cooler parts of the body, hence hairy scalp involvement will naturally be rare. [21],[22]
Two cases with tuberculoid lesion on the hairy occipital area of the scalp, well inside the hairline were reported. [12],[20]
Though rare, the hairy scalp can be involved in the borderline tuberculoid leprosy, and the hair growth may appear normal. [11],[23],[24] Fleury et al. and Malaviya et al. reported plaques and nodules over the scalp in lepromatous leprosy patients. [9],[10]
| Involvement of Palms and Soles | | |
Leprosy affects mainly those areas of skin, which have relatively lower temperature and are more exposed to trauma. [1],[21],[22] Palms and soles are cooler than the rest of the body, more prone to trauma and have rich nerve supply and are thus expected to be involved more frequently. However, they are considered to be rarely involved [Figure 1]. [1],[3]
These areas differ from other superficial areas of the skin in two ways:
- The epidermis is thickest on the palms and soles, measuring approximately 1.5mm which is slightly thicker than that of other superficial skin areas and hence comparatively warmer. [1],[5]
- There is a fairly good amount of fibrofatty tissue which ensures an insulating property and hence a high nerve bed temperature. [1],[25],[26]
Temperature of the nerve bed is directly related to the depth of the tissues. Thus, there is every likelihood of nerve bed temperature of the palmo-planter regions higher than that of other superficial skin regions, on account of the above said reasons, which renders the palmo-planter localization of M. leprae , quite less likely. [26],[27]
Lesions over the palms and soles have been reported by several workers in all types of the disease. [28] Rajendran reported three cases of tuberculoid leprosy with palmo-planter lesions. [26] Aggarwal et al. reported a case of tuberculoid leprosy which presented with a primary annular lesion on the sole of the left foot. [5] Sharma reported 3 histologically confirmed tuberculoid cases involving the sole of the foot. [29]
Chattopadhyay et al. reported a case of borderline tuberculoid leprosy in reaction with lesions over the uncommon sites like palms and soles. [30] Grover et al. reported an uncommon case of borderline tuberculoid leprosy which had primary hyper-pigmented palmar lesion. [31] Pavithran reported primary skin lesions of leprosy on the palm and sole in two patients, one of them having nodular lepromatous leprosy and the other having borderline tuberculoid type of the disease. [32] Baslas reported a case of histoid lepromatous leprosy who had palmar involvement. [33]
Hopkins et al. screened 245 leprosy patients for lesions over certain anatomical locations and found palmar involvement in 17 (6.9%) and planter involvement in 13 (5.9%) cases. [34] Indira et al. carried out a study to assess the frequency of lesions over palms and soles. Of the 280 leprosy patients screened, 28 (10%) showed lesions over the palms and/or soles, 12 (42.8%) had only palmer lesions, 6 (21.4%) had only planter lesions, and 10 (35.7%) had both palmer and planter lesions. Palmoplanter lesions were found in BT, BL and LL types of diseases. [1]
Palmoplanter lesions have also been described in leprosy patients in literature. [1],[30]
| Involvement of External Genitalia and Scrotum | | |
The male external genitalia was considered to be immune to the occurrence of the leprosy lesions, [35] in spite of the lower temperature of the scrotum and testicles, which favors the growth of M. leprae . [36] However, clinical involvement of the external genitalia and scrotal skin has been reported by several workers in all types of the disease spectrum [Figure 2].
Primary involvement of scrotum has been reported in indeterminate [37] and tuberculoid type of leprosy. [38] Single, well-defined anaesthetic plaque was reported over scrotum, [39] preputial skin [40], and over penoscrotal fold [41] in tuberculoid Hansen's disease.
Two different cases with borderline leprosy with a progressive, asymptomatic, hypopigmented, hypoaesthetic plaque situated over the anterior surface of the scrotum, sparing the penile skin completely, [42] and with a primary involvement of the scrotum [43] were reported. Arora et al. found cutaneous lesions of male genitalia in 2.9% of all cases examined. Most of them were of borderline type. [43]
Clinical involvement of scrotal skin in lepromatous leprosy [44] and genital nodules and testicular hydrocele in a case of relapsed lepromatous leprosy [36] were reported. Lesions over the genitalia including glands and scrotum were reported in a case of histoid leprosy. [45],[46]
Six leprosy patients in the Ridley-Jopling spectrum of BT-BL showing lesions on the penis and scrotum were reported. [47]
Histopathological and bacteriological involvement of the scrotal skin in lepromatous leprosy has been documented by Pandya et al. and Ramu et al. [48],[49] In a study by Ramu et al. , scrotal biopsies were obtained from 38 cases of LL who had clinically subsided lesions with negative skin smears. Twenty-six (68.4%) of these cases revealed bacilli in the dartos muscle. None except one showed a specific lesion in the dartos. Bacilli obtained from two out of seven cases multiplied in the mouse foot-pad. [49]
Bhushan Kumar et al. observed 6.6% cases with genital lesions of 467 male patients examined in one study. They were seen most frequently in LL (25.8%) followed by BL (13.3%) and BT (1.4%) leprosy. [50]
Scrotal skin has been reported to be relatively cooler than the core temperature for effective spermatogenesis. [37],[41] However, due to the use of heavy undergarments, it is likely that the temperature of the scrotal skin may remain elevated. [50]
Thus, after various studies and reports, it is not uncommon to find cutaneous lesions of leprosy on male genitalia and scrotum. It seems that paucity in literature of external genitalia and scrotum is due to either to effort by the patient to conceal it or reluctance of doctor or health worker in exposing the patient. [36],[41],[43]
| Involvement of Other Immune Zones in Leprosy | | |
The groin, axillae, perineum, eyelids, midline of back and the transverse band of skin over the lumbosacral area have been described as "immune-zones" with respect to the development of cutaneous lesions of leprosy. [3],[42]
Involvement of groin
Sahni et al. , studied twenty untreated BL and LL cases. They observed groin involvement clinically in five cases, skin-smear positivity in three, while all showed histological changes. [51] Bedi et al. , observed histological involvement of groin in 10 out of 20 lepromatous leprosy patients. [52]
Involvement of axilla
Anish demonstrated higher temperature of the axilla as compared to that of the forearm. [6] The cutaneous lesions of borderline leprosy were found in uncommon sites like axillae and palms and soles. [23] Jayakumar et al. reported a case of advanced lepromatous leprosy having obvious lesions over the scalp and lepromatous infiltration of the axillae and groins. [14]
Midline of back
Hastings et al . reported that even regional temperature differences noted in the cooler lateral back, versus the warmer midline, influenced the bacterial invasion. [53]
The clinical, bacteriological and histopathological features were studied in 20 cases of leprosy (10 LL and 10 BL) from the so-called immune zones that are axilla, groin and midline of back. In these zones the clinical lesions were noted in 40% of the cases (7 LL and 1 BL), AFB were detected in the smears of 45% cases (8 LL and 1 BL) and histopathological evidence of the disease was observed in almost all the sites studied(100%). Midline of back was the commonly affected site [Figure 3], followed by axilla and groin. [51]
Eyelids, perineum, and narrow transverse band of skin over the lumbosacral region
Eyelids, perineum, and narrow transverse band of skin over the lumbosacral region on the back have has also been described to be immune to the development of the lesions in leprosy [3] because of the relatively high local temperature. [2]
Leprous involvement of clinically normal appearing skin
No skin area is immune to the invasion of M. leprae , as studies have documented bacteriological and histological evidence of disease process in clinically uninvolved skin in leprosy patients. [54],[55]
Skin biopsies of clinically normal skin of the scalp, axillary, and groin regions in 20 lepromatous leprosy patients revealed significant histopathological findings in upto 25% of the patients. [52]
| Conclusion | | |
Therefore, it is not uncommon to find cutaneous lesions of leprosy on unusual sites such as scalp, palms and soles, genitalia, groins, axillae, eyelids, transverse band of skin over lumboscaral area, midline of back and perineum which should be termed as relatively immune, rather than absolutely immune zones of leprosy.
| References | | |
| 1. | Indira D, Kaur I, Sharma VK, Das A. Palmoplantar lesions in leprosy. Indian J Lepr 1999;71:167-71.  |
| 2. | Tutakne MA, Das KD, Aggarwal SK. Site of localization of lesions in TT and BT leprosy. Med J Armed Forces India 1983;34:141-3. |
| 3. | Cochrane RG, Davey TF. Ulnar and lateral popliteal nerve involvement in Relation to low temperature zones. In: Leprosy in theory and practice. 2 nd ed. Bristol: John Wright and Sons Ltd; 1964. p. 266. |
| 4. | Jopling WH, McDougall AC. The disease. In: Handbook of leprosy. 5 th ed. New Delhi: CBS Publications; 1996. p. l0-49. |
| 5. | Aggarwal SK, Arora PN, Chattopadhyay SP, Ramakrishnan KR. Primary Involvement of sole in leprosy. Indian J Lepr 1987;57:472-3. |
| 6. | Anish SA. The relationship between surface temperature and dermal Invasion in lepromatous leprosy. Int J Lepr Other Mycobact Dis 1971;39:838-51. |
| 7. | Parikh DA, Oberai C, Ganapati R. Involvement of scalp in leprosy-a case report. Indian J Lepr 1985;57:833. |
| 8. | Parikh AC, D'Souza NA, Chulawale R, Ganapathi R. Leprosy lesion on the scalp. Lepr India 1974;46:39-42. |
| 9. | Fleury RL, Tolentino MM, Opromolla OVA, Tonello C. Inapparent lepromatous leprosy in the scalp. Int J Lepr 1973:580. |
| 10. | Malaviya GN, Girdhar BK, Husain S, Ramu G, Lavania RK, Desikan KV. Scalp Lesions in a lepromatous leprosy patient- case report. Indian J Lepr 1987;59:103-5. |
| 11. | Shaw IN, Ebenezer G, Babu B, Rao GS. Borderline tuberculoid leprosy of the scalp. Lepr Rev 2001;72:357-61. |
| 12. | Ghorpade A, Ramanan C, Manglani PR. Tuberculoid leprosy on hairy scalp. A case report. Lepr Rev 1988;59:235-7. |
| 13. | Chattopadhyay SP, Gupta CM. Primary hyperpigmented cutaneous lesions in tuberculoid leprosy. Indian J Lepr 1988;60:63-5. |
| 14. | Jaikumar J, Aschhoff M, Renuka G, Meyers WM. Involvement of scalp, axillae and groins in lepromatous leprosy. Indian J Lepr 1992;64:541-4. |
| 15. | Oteiz SA, Pinegro RR. Alopecia in leprosy. Bol. Soc Cerbana Dermat J Sifilog 1960;17:26. |
| 16. | Bechelli LM, Silva DA, Oliviera AB. On the histopathological findings in biopsies of apparently normal skin in cases of leprosy. Int J Lepr 1945;13:175. |
| 17. | Faget GH. Alopecia leprosa in United States. Int J Lepr 1946;14:42. |
| 18. | Mistuda K. Atlas of leprosy. Okayama Japan: Chotokai Foundation;1952. p. 65. |
| 19. | Jopling WH, McDougall AC.The disease. In: Handbook of leprosy. 5 th ed. Oxford Heinemann; 1996. p. 23-4. |
| 20. | Ghorpade A, Remanan C, Manlani PR. Tuberculoid leprosy involving hairy scalp. A case report. Ind J Dermatol Venereal Leprol 1994;60:41-2. |
| 21. | Feldman WH. Inducing pathogenesis of M. leprae in animals. Conference report. Publ Hlth. Rep, Washington 1956;71:995. |
| 22. | Binford CH. Comprehensive programme for inoculation of human leprosy into laboratory animals. Conference report. Publ Hlth. Rep, Washington 1956;71:995. |
| 23. | Dharmendra, Ramu G. Borderline (Dimorphous group). In: Dharmendra editor. Leprosy. 1 st ed. Bombay: Kothari Medical Publishing House; 1978. p. 80. |
| 24. | Petro TS. Borderline tuberculoid leprosy lesion on the scalp presenting with supra orbital neuritis. Indian J Lepr 1998;70:319-20. |
| 25. | Enna CD, Berghtholdt HT, Stockwell F. A study of surface and deep temperatures along the course of the ulnar nerve in the pisohamate tunnel. Int J Lepr Other Mycobact Dis 1974;42:45. |
| 26. | Rajendran N. Palmoplantar lesions in paucibacillary leprosy- unusual clinical expressions. Indian J Lepr 1987;59:188-90. |
| 27. | Sabin TD, Hackett ER, Brand PW. Temperature along the course of certain nerves often affected in lepromatous leprosy. Int J Lepr 1974; 42:41. |
| 28. | Mukerjee N, Ghosh S, Kundu S. Palmar lesion in a case of leprosy of the tuberculoid type. Int J Lepr 1958;29:245. |
| 29. | Sharma R Murthy KP, Sekar B. Plantar lesions in tuberculoid leprosy-a report of three cases. Lepr Rev 1994;65:402-4. |
| 30. | Chattopadhyay SP, Rajpathak SD, Gopal AR, Patra AK. Bilateral involvement of sole and palm in leprosy-a case report. Indian J Lepr 1989;61:266-7. |
| 31. | Grover S, Singh G, Dash K. Primary hyperpigmented palmar lesion-a rare presentation of borderline tuberculoid leprosy. Indian J Lepr 1997;62:191-3. |
| 32. | Pavithran K. Primary involvement of the palms and soles in leprosy-report of two cases. Indian J Lepr 1990;62:123-5. |
| 33. | Baslas RG, Gupta M, Arora SK, Mukhija RD, Misra RK. Palmar involvement in histoid leprosy. Indian J Lepr 1992;64:193-5. |
| 34. | Hopkins R, Denney OE, Johansen FA. Immunity of certain anatomic regions from lesions of skin leprosy. Arch Dermatol 1929;20:767-79. |
| 35. | Fox H, Knott J. Leprous nodules of male gentalia. Int J Lepr 1934;2:445-6. |
| 36. | Ebenso BE. Genital nodules and testicular hydrocele in a case of relapsed lepromatous leprosy. Lepr Rev 2000;71:81-2. |
| 37. | Murthy PM, Hegde R, Chandrashekar HR. Primary involvement of scrotal skin in indeterminate leprosy. Indian J Lepr 1993;65:101-2. |
| 38. | Dixit VB, Chaudhary SD, Jain VK, Sen R. Primary involvement of scrotum in tuberculoid leprosy. Indian J Lepr 1990;62:120-2. |
| 39. | Inamdar AC, Kumar GK. Genital skin lesion in tuberculoid Hansen's disease-letter to the editor Indian J Dermatol, Venereal and Leprol 1992;58:49. |
| 40. | Maru S, Mittal A, Gupta L, Sharma M, Bansai N. Penile lesion in Hansen's disease. Int J Lepr 1996;64:324-5. |
| 41. | Ghorpade A, Ramanan C. Solitary tuberculoid leprosy lesion over penoscrotal fold. Indian J Lepr 1998;70:317-8. |
| 42. | Kachhawa D, Salodkar AD, Khullar R, Singhi MK, Kalla G, Vyas MC. Scrotal lesion in borderline leprosy. Indian J Lepr 1993;65:447-8. |
| 43. | Arora SK, Mukhija RD, Mohan L, Girdhar M. A study of cutaneous lesions on male genitalia. Indian J Lepr 1989;61:222-4. |
| 44. | Thappa DM, Kumar RH, Karthikeyan, Ratnakar C. Scrotal lesions in lepromatous leprosy. Indian J Lepr 1999;71:223-7. |
| 45. | Nigam PK, Singh G. Mucosal and genital lesions in histoid leprosy. Int J Dermatol 1990;29:207-8. |
| 46. | Ramanujan K, Ramu G. Wade's histoid lepromatous leprosy. Report of a clinical study. Lepr India 1969;41:293-7. |
| 47. | Parikh DA, Parikh AC, Ganapati R. Penile and scrotal lesions in leprosy case reports. Lepr Rev 1989;60:303-5. |
| 48. | Pandya NJ, Antia NH. The value of scrotal biopsy in leprosy. Lepr Rev 1974;45:145-52. |
| 49. | Ramu G, Desikan KV. A study of scrotal biopsy in subsided cases of lepromatous leprosy. Lepr India 1979;51:341-7. |
| 50. | Kumar B, Kaur I, Rai R, Mandal SK, Sharma VK. Involvement of male genitalia in leprosy. Lepr Rev 2001;72:70-7. |
| 51. | Sahni U, Reddy BS, Malik R. Clinicopathological study of so called immune zones in leprosy. Lepr India 1982;54:256-62. |
| 52. | Bedi TR, Kumar B, Kaur S. Histopathologic study of clinically normal appearing skin in lepromatous leprosy. Lepr India 1979; 51:78-80. |
| 53. | Hastings RC, Brand PW, Mansfield RE, Ebner JD. Bacterial density in the skin in lepromatous leprosy as related to temperature. Lepr Rev 1968;39:71-4. |
| 54. | Kaur S, Kumar B. Study of apparently uninvolved skin in leprosy as regards bacillary population at varying sites. Lepr India 1978;50:38. |
| 55. | Katoch VM, Mukherjee A, Girdhar BK. A bacteriological and histopathological study of apparently normal skin in lepromatous leprosy. Lepr India 1980;52:508-12. |
[Figure 1], [Figure 2], [Figure 3] |
|
| This article has been cited by | | 1 |
“Deck chair sign” presenting in type 1 lepra reaction |
|
| Amina Asfiya, ManjunathMala Shenoy, VishalB Amin, Malcolm Pinto, SpandanaPrakash Hegde, AshmiyaAbdul Razak | | Archives of Medicine and Health Sciences. 2021; 9(1): 171 | | [Pubmed] | [DOI] | | | 2 |
Pitfalls in the diagnosis of leprous neuropathy: Lessons learnt from a University hospital in an endemic zone |
|
| Madhu Nagappa, Yasha T. Chickabasaviah, Anita Mahadevan, Raja Parthiban, Arun B. Taly | | Journal of the Neurological Sciences. 2015; 357(1-2): 252 | | [Pubmed] | [DOI] | |
|
|
|
|
|
|
|
|
|
