October 2000, Volume 50, Issue 10

Original Article

Relationship of Skin Ulcers and Physical Deformity with Employment Status and Compliance with Health Promotion in Leprosy

Heinke Kunst  ( Tropeninstitute. Gottingen, Germany and Marie Adelaide Leprosy Centre, Karachi. )


Objective: To deterrnirte if recurrence of ulcers and physical deformity in leprosy is associated with employment status and compliance with health promotion advice.
Methods: Between April-August 1992, a cohort of 55 consecutive leprosy patients admitted with skin ulcers were studied for ulcer recurrence, physical deformity (taking into account neuromuscular and skeletal damage), employment status, compliance with health promotion advice and knowledge of the disease.
Results: High grade physical deformity was present in 34/55 (62%) patients while recurrent ulceration occurred in 40/55 (75%) patients. With regard to employment status, the odds of high grade physical deformity were significantly higher for street traders and unemployed compared to semiskilled and skilled workers (odds ratio 4.2, 95% confidence interval 1.01 -19.8, p = 0.03). There was a trend of higher odds of recurrence of ulcers for street traders and unemployed compared to semiskilled and skilled workers (odds ratio 2.3, 95% confidence interval 0.5-9.4, p = 0.2). With regard to health promotion, there was poor compliance with advice about protective footwear and care of insensitive extremities. Level of knowledge about the disease and its prevention was also inadequate.
Conclusion: Physical deformity was associated with lack of reasonable employment among leprosy patients. There was poor compliance with preventative advice. Health promotion strategies should be directed toward targeted health education and prevention of physical deformities UPMA 50:338, 2000).


Since the introduction of mutli-drug therapy in leprosy control, the prevalence of leprosy patients has declined steadily. However there is still a high percentage of patients with sensory and motor neuropathies who are at risk of progressive physical deformity and recurrent ulcerationt1,2. Primary deformity is due to the activity of the disease, however, secondary deformity is due to damage which the patient inadvertently self-inflicts as a consequence of anesthesia or paralysis1. The WHO3 emphasized that prevention of physical deformity and ulcers is important and that patients with a sensory loss of their feet should follow a schedule of precautions including daily examination of feet regarding injuries and blisters, protective footwear, reduction of walking especially once there are signs of an injury or an infection. Therefore, health education to prevent recurrent ulceration of anesthetic skin and physical deformity of the limbs should be a priority.
We often forget that a lot of patients do not accept their disease and refuse to wear orthopedic shoes4 or to take regular care of their insensitive hand and feet. Moreover, employment can prevent the patients from protecting their skin from injuries and ulceration. Sadly, once affected by secondary deformity or recurrent ulceration, the patient is at risk of unemployment. This study was conducted to determine if recurrence of ulcers and physical deformity in leprosy was associated with employment status and compliance with health promotion advice.

Patients and Methods

During the period April to August 1992, a cohort of 55 consecutive patients with skin ulcers requiring hospitalization were evaluated at the Marie-Adelaide Leprosy Centre, Karachi, Pakistan. All patients had received regular health education by trained teachers in the past and each patient had been given advice about adequate footwear5,6 and had been offered special orthopedic shoes. The suggested methods of prevention included daily inspection of anesthetic hand and feet regarding skin injuries, regular baths and care with Vaseline afterwards to restore loss of seborrhoic function.
On admission, a detailed assessment including disease duration, ulcer location and recurrence and grading of general physical deformity was conducted. The occupation of the patient, appropriateness of footwear and their knowledge of the disease and methods for prevention of ulcers were, recorded. Physical deformity was classified as high grade if deformity included moderate bony absorption, nerve palsies with subsequent contractures and functional loss of hand and feet2. Nerve palsies without contractures, minor bony absorption without functional loss of hand and feet were classified as low grade physical deformity2. Employment history was classified as unemployed, street traders, semiskilled factory workers, skilled workers and housewives.
The effect of high grade deformity on employment status was studied by comparing street traders and unemployed to semiskilled and skilled workers. This comparison was chosen because street traders had taken this occupation as a result of unemployment. Housewives were excluded from this analysis. The association of recurrence of ulceration with employment was evaluated according to the above groups using recurrence over a period of more than five years for analysis.
Information on compliance with advice about use of protective footwear was analyzed according to grade of physical deformity. Rate of daily inspection and care of insensitive extremities among patients with recurrent ulcers was estimated. Patients with recurrent plantar ulcers for more than five years had a detailed interview about causes and prevention of ulcers. Epi-info Software7 was used for statistical analysis. Proportions were assessed for differences using Chi-square test (with Yate\\\'s correction when expected cell value “as <5). A two tail p-value of <0.05 was regarded as significant.


Table I shows the general characteristics of the patients studied. There were 40 male and 15 female patients. The mean age was 49.3 years and mean duration of disease 14.2 years. Forty patients had recurrent ulcers and the mean time of recurrence was 5.6 years (range 6 months to 24 years). Of these, 2 I patients showed recurrence of ulceration over more than five years. Out of 55 patients, 34 had a high grade physical deformity. Employment history revealed that 15 patients were unemployed, 7 were street traders, l4 were semiskilled factory workers, 6 were skilled workers and 13 were housewives.

As shown in Table 2, high grade deformity was found in 13/I5 unemployed patients, 4/7 street traders, 6/14 factory workers and 3/6 skilled workers. The odds of high grade physical defonnity were significantly higher for street traders and unemployed compared to semiskilled and skilled workers (odds ratio 4.2, 95% confidence interval 1.01-19.8, p = 0.03). Recurrent ulcers over more than five years occurred in 7/IS unemployed patients, 5/7 street traders, 4/14 factory workers and 3/6 skilled workers. There was a trend of higher odds of recurrence of ulcers for street traders and unemployed compared to semiskilled and skilled workers (odds ratio 2.3, 95% confidence interval 0.5-9.4, p = 0.2). Among housewives high grade deformity occurred in 9/13 and recurrent ulceration of the skin was only seen in 2/13.
Compliance with advice that use of protective footwear showed that only 3/21 (14%) patients with low grade deformity used such protection compared to 20/34 (59%) in the high grade deformity group (P<=0.001). Only 22/40 (55%) patients with recurrent ulcers used daily inspection and care of their insensitive extremities. The remainder inspected their insensitive hands and feet occasionally or never. There were 2 I patients with recurrent plantar ulcers for more than live years and we questioned them in depth about cause and prcvention. Of these, 18 completed the interview and their responses are summarised in Table 3.

Of 18 respondents, 12 were aware of a sensory loss which lead to ulceration and 8 knew the first signs of ulceration like blisters or redness. Regarding prevention of ulcers, 11/18 indicated daily inspection, however, they ignored daily care such as removal of pressure points, scar massage etc.


Our results showed that high grade physical deformity and recurrent ulceration was common among hospitalized leprosy patients. With regard to employment status, the high grade of physical deformity was associated with unemployment. There was also a trend of higher unemployment among those with recurrent ulcers. With regard to health promotion, there was poor compliance with advice about protective footwear and care of insensitive extremities. Level of knowledge about the disease and its prevention was also inadequate.
Similar to our findings, other authors have described a high deformity rate among leprosy patients who are illiterate or unskilled8-10. On the one hand, hard manual work leads to serious deformity10. On the other, it has also been shown that deformity leads to a significant loss of production of leprosy patients11. In addition to the issue of deformity, it has been described in a questionnaire of leprosy patients and the public that 2/3 of the interviewed indicated that leprosy patients should be excluded from the majority of occupations12.
With regard to use of footwear, in our study, it was evident that patients only realised the necessity of protective shoes, when a deformity was already present. Many patients who feel stigmatised by their disease and especially by their deformity want to be accepted by society like other people. They want to walk as fast as possible and they refuse shoes, which show that they are handicapped4. It has been shown that many patients refuse microcell rubber-shoes because of the stigma they carry13. However it is important that patients use protective shoes in order to prevent the first ulcer14. One field project looked at outcome of prevention of plantar ulcers by supply of appropriate shoes and health education. Satisfying results were only found in patients who did not show ulcers at the beginning of the examination compared to those who already had pre-existing ulcers15.
Majority of our examined patients were aware of the insensitivity of their extremities, however, few realised its consequence for their every day life. Only a few patients could remember detailed facts of their disease such as first signs of an ulcer, although each patient had intensive health education at the onset of their disease and also subsequently during follow-up clinics. It has been shown that ulcers remain healed even without special footwear if patients learn to modify their gait with respect to change of pressure points16. Majority of our patients had some idea how to modify the gait, however, none of the patients remembered the importance of change of pressure points in prevention of food ulceration. Regarding other methods of prevention a lot of patients indicated daily inspection of their hand and feet, however only a few remembered to also apply daily care like daily soaking in water, scar massage and removal of scar tissue.
In conclusion we realised that a lot of leprosy patients try to repress their disease and do not acknowledge the importance of prevention of ulcers and adequate footwear until they develop deformities. Price17 demonstrated that practical advice like demonstration of preventative methods compared to theoretical advice was more remembered by patients. There are limited resources for providing resource intensive treatments to allow full development of people affected with leprosy18, therefore it is important to provide more intensive counselling for the patient who fears stigmatisation of society.


The author is grateful to Prof. W. Bommer of the Tropeninstitut, Gottingen, Germany for his support and supervision in her doctoral thesis work on which this paper is based; to Drs. T. Chiang and R. Pfau of the Marie Adelaide Leprosy Centre, Karachi, Pakistan for allowing her to study their patients and to the patients themselves who willingly consented to participate in this work.


1. Noordeen SK, Paaniker VK. Leprosy. In Cook GC (ed). Manson’s Tropical Diseases. London; WB Saunders, 1996., pp 1016-44.
2. Kunsi 11 Skin ulceers in Leprosy patients in Karachi, Pakistan: Predisposing factors for reccurrence of ulcers (MD thesis) Goitingen. Gennany, University of Gottingen, 1993.
3. World Health Organisation. WIHO Expert Conuninee on Leprosy. Sixth Report. WHO Tech Rep. Ser.1988. No 768.
4. Jopling Wil. Planter ulceration in Leprosy. Lcpr. Rev., 1969; 40: 175.
5. Kaplan M, Gelber II. Care of plantar ulceration, comparing application, materials and non-casting. l.epr Rev., 1988; 59’ 59-66.
6. Dean AG, Dean JA, Couloinbier D, ci al. Epi Info. Version 6: A Word. Processing. Database and statistics program. Atlanta, Georgia, Centers for Disease Control and Prevention, (CDC) 1994.
7. Girdhar M, Arora SK, Mohan L. Patient of leprosy disabilities in Gorakhpur (Uttar pradesli). India. J. Lepr., 1989; 61: 501-3.
8. Reddy BN, Bansal RD. An epideiniological study of leprosy disabilities in a lerposy endemic rural population of Pondieherry (South India). l.epr. India, 1984; 56: 191-99.
9. Kotucha KK, Padc SS, Nair PR. ci al. Lerposy among industrial workers in Bombay, India. Studies in retrospect and prospect. tnt J. Lepr, 1984; 52: 488-95.
10. Max E, Sliepard DS, Productivity loss due to defonnity from leprosy in India Int. J. Lepr., 1989; 57: 476-82.
11. Lcnnon Li. A review of health education in leprosy. Int. 3. Lepr.. 1988; 56:611-18.
12. Kulkarni VN. Antia Nil, Media JM. Newer design in footwear for leprosy patients. Indian J. Lepr., 1990: 62: 483-87.
13. Watson JM. Disability control in a leprosy programme. Lepr Rev., 1989; 60:169-77.
14. 1 lirzel C, Milliam 3, Boucher P, et al. Prevent ion of perforating ulcers: trial dircctcd by a mobile leant. Acta Lepr.. 1986; 4: 79-92.
I5. Pike EW. Surgical rehabilitation in leprosy plantar ulcers. Baltimore, The Williams Wilkonsons Company, 1974, pp. 373-81.
16. Price JR. A study of lcrposy patents with deforinilies and implications for the treatment of all lerposy patients. Lepr. Rcv,, 1983: 54: 129-37.
17. Walter CS. Social aspect and rehabilitatiotion Lepr. Rev, 1999;70:85-94.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: