From Conundrums to Consensus: Addressing Gaps in the Management of Leprosy

Persistent/partially regressed, expanding/spreading, or newly appearing lesions after completion of multidrug therapy remain some of the most challenging gray zones in the clinical management of leprosy. Distinguishing between slowly regressing granulomas, immunologically driven activity, relapse, drug resistance, and reinfection is complex, particularly in settings where advanced diagnostics are limited. This perspective synthesizes current evidence to propose a structured, algorithmic approach integrating slit-skin smears and histopathology along with where available, molecular viability assays. We highlight scenarios of persistent lesions, increased size of pre-existing lesions, appearance of new lesions, and posttreatment nerve function impairment, outlining key differentiators and suggesting practical management pathways. The article underscores the need for individualized approaches for patients with high bacillary loads, broader access to molecular diagnostics, and improved posttreatment surveillance. A unified framework for labeling such cases as "recurrence" should be avoided in field-level reporting as even if it maintains clinical nuance, it does not provide a clear picture of the underlying etiology. These strategies aim to reduce misclassification, improve outcomes, and minimize missed opportunities for early retreatment/management.