A look at the latest research by Dr Indra Napit in Nepal
Ulcers are very common amongst leprosy patients, with up to 20 percent of people affected by leprosy being at risk of developing an ulcer. These are wounds that occur because people lose feeling in a part of their body - in other words, communication is disrupted between the brain and, most commonly, the foot.
This means they may not feel, for example, if there is a stone in their shoe that is damaging the skin. Even the sweat glands lose communication, and the skin of the foot dries and easily cracks open, becoming vulnerable to infection.
After the first ulcer, it is likely that ulcers will recur for the rest of a person’s life, causing devastating disruption. In places where walking is central to transport and work, leprosy ulcers can lead to a downward spiral of losses over time including income, job, community, home, family and even limbs. When placed in hospital wards alongside these patients, first-time ulcer patients can develop suicidal thoughts, because they see the other patients’ stories as their own unavoidable future. We need to change that outlook.
TLM Nepal, India and Nigeria are working on a large ulcer project, which includes lots of smaller projects, with partners from across the world.
In Nepal, Dr Indra Napit leads two of the projects investigating new approaches to foot ulcers caused by leprosy. He and his team are looking at how community interventions can prevent ulcers, and how a new, revolutionary ulcer treatment could transform a patient’s outcome.
Prevention is better than any treatment, so Dr Indra and his team are looking into how communities can be equipped and mobilised to prevent ulcers from occurring.
Through the SHERPA Project, the team are tracking the work of 18 self-help groups (SHGs) across three districts of Nepal. These SHGs are trained in how to prevent ulcers and are supported by our team so that they have different tools for self-help.
Our team wants to research which interventions work best, which will be done by periodically interviewing participants and measuring what did or did not help prevent ulcers.
One of the interventions they are particularly interested in is financial support. Each SHG has around 25 participants and each group will be given 20,000 rupees (or £125), which can be used as an investment fund and a savings scheme. The money could prove vital in preventing ulcers because it allows SHG members to invest in new livelihood activities. This is crucial in a country where two-thirds of the population are farmers.
When SHGs invest financial support in members, they are able to set up trades and develop their own work that is a better fit or not as physically demanding on their affected limbs, such as tailoring, raising chickens or goats, or running a small shop. This means there are fewer opportunities for them to pick up an injury that could develop into an ulcer.
Once they have completed this research, the team are looking to develop international guidelines on ulcer prevention and self-care. They hope that these guidelines will be submitted to the WHO and will become standard practice across the world. Such a step could prove transformative for hundreds of thousands of people affected by leprosy all over the world.
For as long as people can remember, leprosy ulcers have been treated with a daily saline (salt water) wash and fresh gauze wrap. Dr Indra and his team are trialling a new treatment called L-PRF (Leukocyte Platelet-Rich Fibrin).
This is a regenerative treatment that utilises concentrated white blood cells and regular stem cells that circulate in the blood.
Our blood contains lots of stem cells which our bodies use for regeneration – it’s what causes our hair and nails to grow.
For L-PRF treatment, blood is drawn from the leprosy patient, and then spun in a centrifuge so that the white blood cells, stem cells and other healing factors are concentrated.
Afterwards, the healing mixture is like a gel that is then pressed into strips and applied like a plaster directly to the same patient’s ulcer.
At Anandaban, these healing L-PRF strips have caused leprosy ulcers to heal more quickly, regenerating new tissue without much scarring.
One patient with a foot ulcer covering nearly the entire sole had not healed after a year in hospital with saline treatment and seemed destined for amputation. But, after switching to L-PRF treatment, the ulcer healed within 10 weeks.
As part of the study, Dr Indra is leading the TABLE Project in Nepal, which is a randomised control trial comparing L-PRF with the traditional saline method of treating ulcers. They expect the results from this trial will provide the evidence base that’s needed in order to change international treatment regimens.
The L-PRF method has already been proven to be an effective way of treating diabetic ulcers; and Dr Indra expects very similar results from this trial, with ulcer healing happening far faster than with the traditional saline method. Initial testing at Anandaban Hospital has been encouraging, with one patient even travelling for three days from New Delhi in order to access the treatment.
As well as developing new International Self-Care Guidelines, Dr Indra and his team will look to provide training for leprosy hospitals worldwide, starting with our team in Bangladesh in 2022.
For many people, ulcers are a persistent problem and they find themselves in and out of hospital; their jobs, homes, relationships and limbs are often the price they pay due to these constant hospital stays.
Through preventing ulcers and finding a faster, better treatment for ulcers, these projects will have an enormous legacy in these lives.
