Buruli ulcer is a major cause of morbidity in the regions where it is endemic across 33 countries. The treatment of the disease has changed drastically over the last 15 years with a move away from reliance on wide surgical excision, increased confidence in the efficacy of antibiotics and a better understanding of the pathogenesis of Mycobacterium ulcerans infections.
Antibiotic regimens based on rifampicin for 8 weeks combined with either streptomycin, clarithromycin or a quinolone companion drug are highly effective against M. ulcerans. Excisional surgery and thermotherapy are other potential treatments, although recurrence rates are higher when antibiotics are not prescribed. Healing continues for many months after antibiotic treatment is completed and a recent controlled study has demonstrated that delaying surgical intervention is not deleterious to long-term patient outcomes. Many patients are now treated successfully with antibiotics and dressings alone. Large defects may still require skin grafting once the active Buruli infection has resolved. Paradoxical reactions—clinical worsening despite effective antibiotics—are common particularly in WHO category II and III lesions. Corticosteroids may be useful in severe destructive paradoxical reactions.
A combination of antibiotics and good wound care should result in healing of Buruli ulcer lesions without recurrence. Surgery may still be required in some cases to improve healing and close large defects. Further research is required to determine the optimum antibiotic regimen and duration and the best approach to managing paradoxical reactions during medical therapy.