• Buruli Ulcer, also known as Mycobacterium ulcerans infection, is a tropical disease caused by Mycobacterium ulcerans. It is characterized by the formation of large, ulcerating skin lesions that can lead to significant tissue destruction and functional impairment. Buruli Ulcer is endemic in certain parts of Africa, particularly West and Central Africa, as well as some regions of Australia and other countries.
• The disease is believed to be transmitted through environmental sources, such as water and soil, although the exact mode of transmission is not fully understood. The bacterium produces a toxin called mycolactone, which is thought to contribute to the tissue damage observed in Buruli Ulcer.
• Buruli Ulcer primarily affects children and young adults, but individuals of all ages can also be affected. It is more commonly seen in rural communities with limited access to healthcare and poor sanitation conditions. The disease is often associated with poverty, malnutrition, and inadequate wound care.

• Incidence: Buruli Ulcer is most prevalent in certain regions of Africa, particularly West and Central Africa. It is also found in other parts of the world, including some areas of Australia, South America, and Southeast Asia.
• Geographic Distribution: The disease is primarily found in rural areas, often in communities with limited access to healthcare and poor sanitation conditions.
• Age and Gender: Buruli Ulcer can affect individuals of all ages, but it is most commonly observed in children and young adults.
• Seasonal Variation: There may be seasonal variation in the incidence of Buruli Ulcer, with higher numbers of cases reported during specific times of the year.
• Risk Factors: Risk factors for Buruli Ulcer include living in endemic areas, exposure to stagnant or slow-moving water bodies, poor wound care, and inadequate hygiene practices.
• Transmission: The exact mode of transmission of Buruli Ulcer is not fully understood. It is believed to be transmitted through environmental sources, such as water and soil, with involvement of certain insects or animals.
• Disease Burden: Buruli Ulcer can lead to significant morbidity, including large ulcerating skin lesions, functional impairment, and long-term disabilities if not treated promptly.

• Mycobacterium ulcerans Infection: Buruli Ulcer is caused by an infection with Mycobacterium ulcerans, a slow-growing bacterium belonging to the same family as the bacteria that cause tuberculosis and leprosy.
• Entry and Localized Infection: The exact mode of transmission of M. ulcerans is not fully understood, but it is believed to enter the body through a break in the skin, such as a cut, abrasion, or insect bite. The bacterium then establishes a localized infection in the subcutaneous tissue.
• Toxin Production: M. ulcerans produces a unique toxin known as mycolactone, which plays a crucial role in the pathogenesis of Buruli Ulcer. Mycolactone has cytotoxic and immunomodulatory effects, leading to tissue damage and immune suppression.
• Immune Response and Tissue Destruction: The immune response to M. ulcerans infection is typically limited and ineffective, allowing the bacteria to evade elimination by the host immune system. The mycolactone toxin contributes to tissue destruction by causing necrosis (cell death) and inhibiting immune cell function.
• Localized Skin Lesions: The primary manifestation of Buruli Ulcer is the development of painless, subcutaneous nodules or plaques that progress to ulcerated skin lesions. The ulceration is a result of the tissue damage caused by the bacterium and its toxin.
• Spreading of Infection: If left untreated, the infection can spread deeper into the subcutaneous tissue, affecting larger areas of skin, muscles, and even bones. This can lead to extensive tissue destruction, functional impairment, and long-term disabilities.

• Mycobacterium ulcerans: Buruli Ulcer is caused by infection with the bacterium Mycobacterium ulcerans. This bacterium is classified within the same family as the bacteria that cause tuberculosis and leprosy.
• Environmental Reservoir: The exact reservoir and mode of transmission of M. ulcerans are not fully understood. However, it is believed to reside in environmental habitats such as wetlands, stagnant water bodies, and aquatic insects.
• Inoculation: The bacteria can enter the body through breaks in the skin like cuts, abrasions, or insect bites. The exact mechanisms of transmission are not well-established, but it is thought that contact with contaminated water or soil may play a role.
• Factors Influencing Susceptibility: Certain factors may increase the risk of developing Buruli Ulcer, including residing in or frequenting endemic areas, exposure to contaminated environments, and host-related factors such as immunodeficiency or compromised skin integrity.
• Geographic Distribution: Buruli Ulcer is found in tropical and subtropical regions of Africa, with the highest burden reported in West and Central Africa.

• Delayed Diagnosis and Treatment: Early diagnosis and timely initiation of appropriate treatment are crucial for better outcomes in Buruli Ulcer. Delayed diagnosis and treatment can lead to larger ulcer sizes, extensive tissue damage, and increased risk of complications.
• Lesion Characteristics: The size, location, and severity of the ulcer are important prognostic factors. Larger ulcers, particularly those involving joints or bones, are associated with poorer outcomes and a higher risk of functional impairment.
• Delayed Healing: Slow or delayed wound healing is associated with an increased risk of complications and prolonged disability. Factors that can affect healing include wound size, presence of necrotic tissue, and underlying health status.
• Functional Impairment: Buruli Ulcer can cause functional limitations and disability, especially if it affects critical areas such as joints or causes deformities. The extent of functional impairment can impact the prognosis and long-term outcomes.
• Scarring and Deformities: Severe scarring and deformities resulting from Buruli Ulcer can lead to functional limitations and psychosocial impacts. The severity and extent of scarring and deformities can influence the prognosis and quality of life.

Age Group: Buruli Ulcer can affect individuals of all ages, but it is most observed in children aged 5-15 years in endemic areas. However, cases have been reported in individuals of all age groups, including adults and the elderly.

Associated Comorbidity or Activity: Buruli Ulcer is often associated with rural and agricultural activities, as well as living in or near wetland environments. Individuals who engage in activities such as farming, fishing, or spending significant time in water are at a higher risk. However, Buruli Ulcer can affect individuals regardless of their occupation or activity.

Acuity of Presentation: The onset of Buruli Ulcer is usually insidious, with a slow and painless progression of skin lesions. The initial signs may include a painless nodule, papule, or plaque that gradually enlarges and ulcerates over time. Some common characteristics of Buruli Ulcer include undermined edges, necrotic tissue in the ulcer, and surrounding edema.

Skin Examination:

Inspection: Observe the skin for characteristic lesions, including flaccid blisters, erosions, crusts, and areas of denuded skin.

Distribution: Note the distribution pattern of lesions, which often affects the scalp, face, upper trunk, and flexural areas.

Severity: Assess the extent and severity of skin involvement, ranging from localized to generalized disease.

Oral Examination:

Inspection: Examine the oral cavity, including the lips, buccal mucosa, gingiva, and tongue, for erosions, ulcers, or blisters.

Localization: Note the distribution of oral lesions, which commonly involve the buccal mucosa, gingiva, and palate.

Severity: Evaluate the extent and severity of oral involvement, which can vary from mild to severe.

Mucosal Examination:

Inspection: Assess other mucosal surfaces, such as the conjunctiva, nasal mucosa, genital mucosa, and anal mucosa, for erosions or blisters.

Localization: Determine the distribution pattern of mucosal lesions and note any specific areas involved.

Severity: Evaluate the extent and severity of mucosal involvement, which can vary among patients.

Nikolsky Sign:

Evaluation: Perform the Nikolsky sign by applying gentle lateral pressure to unaffected skin adjacent to a blister or erosion. Assess for the development of a new blister or extension of the existing lesion, indicating a positive sign.

Skin Biopsy:

Procedure: In some cases, a skin biopsy may be necessary to confirm the diagnosis of pemphigus vulgaris. This involves obtaining a small sample of skin tissue for histopathological examination.

Medical Management:

• Antibiotic therapy: The primary treatment for Buruli Ulcer involves a combination of antibiotics, such as rifampicin and clarithromycin or streptomycin. The antibiotics are usually administered for an extended duration, typically ranging from 8 to 12 weeks.
• Supportive care: Pain management, wound care, and monitoring for any signs of infection or complications are essential components of medical management.
• Surgical Interventions:
• Debridement: Surgical removal of necrotic tissue and debris is often necessary to promote wound healing and prevent further spread of the infection.
• Skin grafting: In cases where there is significant tissue loss, skin grafting may be performed to facilitate wound closure and improve functional and cosmetic outcomes.

Supportive Care:

• Pain management: Adequate pain control is crucial, and appropriate analgesics may be prescribed as needed.
• Wound care: Regular dressing changes, cleaning of the ulcer, and application of appropriate wound care products are essential for optimal healing.
• Rehabilitation: It is recommended to restore functionality and minimize disability.

Dermatology, General

Lifestyle modifications: 

• Wound Care and Hygiene: Proper wound care is essential to prevent infection and promote healing. This includes cleaning the wound with mild antiseptics or sterile saline, removing necrotic tissue, and applying appropriate dressings. Regular wound cleaning and dressing changes are necessary to maintain a clean and moist environment.
• Limb Immobilization: In some cases, limb immobilization may be necessary to prevent movement and minimize tension on the affected area. Immobilization techniques, such as splints or casts, help protect the wound and reduce the risk of complications.
• Pain Management: Adequate pain management is crucial to ensure patient comfort. Non-steroidal anti-inflammatory drugs (NSAIDs) or other pain relievers may be prescribed to alleviate pain and inflammation associated with the ulcer.
• Nutritional Support: Malnutrition can negatively affect wound healing. Therefore, maintaining adequate nutrition is important for the healing process. Nutritional assessment and supplementation, if necessary, may be recommended by healthcare professionals.
• Psychological Support: Coping with a chronic wound can be mentally and emotionally challenging. Providing psychological support, counselling, and education to patients and their families is an important part of the overall management of Buruli Ulcer.

Dermatology, General

• Category I: Early Disease (For ulcers less than 5 cm)

This category includes early-stage Buruli Ulcer with small, well-defined ulcers or nodules without any signs of deep involvement.

Treatment consists of an 8-week regimen of oral antibiotics, usually rifampicin and clarithromycin or rifampicin and streptomycin.

• Category II: Moderate Disease (For lesions more than 5 cm)

This category includes moderate-stage Buruli Ulcer with larger or multiple ulcers, involvement of joints or bones, or extensive edema.

Treatment consists of an 8-week regimen of oral antibiotics combined with a 4-week course of streptomycin injections or intramuscular amikacin.

• Category III: Advanced Disease (For lesions more than 15 cm)

This category includes advanced-stage Buruli Ulcer with extensive ulcers, involvement of vital structures (e.g., face, genitals), or extensive functional limitation.

Treatment consists of an 8-week regimen of oral antibiotics combined with a 4-week course of streptomycin injections or intramuscular amikacin. Surgical intervention may also be required for debridement or reconstructive procedures.

Dermatology, General

• Rifampin: It is typically prescribed at a dose of 10 to 15 mg/kg/day orally, up to a maximum of 1200 mg daily. Rifampin is often combined with other antibiotics for an effective treatment regimen.
• Macrolide (Clarithromycin): Oral clarithromycin is frequently used in combination with rifampin. The recommended oral dose is 500 mg once or twice daily.
• Aminoglycoside (Streptomycin): Streptomycin is administered as intramuscular injections and is often used in combination with oral antibiotics. The duration and frequency of streptomycin injections may vary depending on the severity.
• Fluoroquinolone: Rifampin can be combined with a fluoroquinolone such as moxifloxacin, ciprofloxacin, levofloxacin, or ofloxacin. This combination has shown effectiveness in treating Buruli Ulcer.
• Dapsone: The combination of rifampin with dapsone has demonstrated some reduction in ulcer size. The dosing and duration may vary based on individual patient factors.

Other regimens:

• Combination of Rifampin with a Fluoroquinolone: This combination involves the use of rifampin in combination with a fluoroquinolone antibiotic such as moxifloxacin, ciprofloxacin, levofloxacin, or ofloxacin. This combination has shown effectiveness in treating Buruli Ulcer and is an alternative to the rifampin-clarithromycin regimen.
• Combination of Rifampin with Dapsone: The combination of rifampin with dapsone has demonstrated some reduction in ulcer size in patients with Buruli Ulcer. However, the use of this combination may vary depending on the specific circumstances and individual patient factors.

Dermatology, General

Topical therapies are sometimes used as adjunctive treatments in the management of Buruli Ulcer. These therapies aim to support wound healing and control bacterial infection.

Nitrogen Oxide: Nitrogen oxide-based gels or ointments may be applied topically to the ulcerated area. Nitrogen oxide has antimicrobial properties and can help inhibit growth of bacteria in the wound.

Phenytoin Powder: Phenytoin, an antiepileptic medication, has been shown to have wound healing properties. Phenytoin powder may be applied topically to the ulcer to promote healing and prevent infection.

Local Heat: Application of local heat, such as warm compresses or warm water soaks, may help to improve blood circulation and promote healing. It can also provide symptomatic relief by reducing pain and inflammation.

Dermatology, General

• Surgical Debridement: Surgical debridement involves the removal of infected or necrotic tissue from the ulcer site. This procedure helps to eliminate the source of infection and allows for the healthy tissue to regenerate. Debridement can be performed using various techniques, such as sharp debridement (using a scalpel or scissors) or mechanical debridement (using a high-pressure irrigation system). The extent of debridement depends on the severity and extent of the ulcer.
• Skin Grafting: Skin grafting is a procedure where healthy skin from one part of the body (donor site) is transplanted to the ulcer site (recipient site). This technique helps to cover the ulcer, promote healing, and improve cosmetic appearance. Skin grafts can be split-thickness grafts (epidermis and part of the dermis) or full-thickness grafts (epidermis and full dermis). The choice of graft type depends on the size and depth of the ulcer.

Dermatology, General

• Acute Phase: The acute phase refers to the initial stage of Buruli Ulcer where prompt diagnosis and early initiation of treatment are crucial. During this phase, the primary goals are to confirm the diagnosis, initiate appropriate antibiotic therapy, and assess the extent and severity of the ulcer. Wound care and pain management are also important aspects of the acute phase.
• Intensive Phase: The intensive phase involves a more aggressive approach to the treatment of Buruli Ulcer. It typically lasts for several weeks and aims to control the infection, promote wound healing, and prevent complications. The primary treatment during this phase involves the use of antibiotics, either orally or intravenously, as determined by the severity of the infection. Wound care, including debridement and dressings, is continued to facilitate healing.
• Healing Phase: The healing phase focuses on the promotion of wound healing, resolution of the infection, and restoration of normal tissue. This phase may extend over several weeks to months, depending on the size and depth of the ulcer. Wound care remains a key component, with regular cleaning, dressing changes, and monitoring for signs of healing or recurrence. Physical therapy and rehabilitation may also be included to improve function and mobility.

Dermatology, General

Water Exposure: Avoiding prolonged contact with stagnant or slow-flowing water bodies, such as swamps, rivers, and ponds, can reduce the risk of Buruli Ulcer. This includes minimizing activities that involve frequent exposure to water, such as swimming or wading in endemic areas.

Insect Repellents: Using insect repellents containing DEET (N, N-diethyl-meta-toluamide) on exposed skin can help prevent insect bites and reduce the risk of transmission.

BCG Vaccination: Bacillus Calmette-Guérin (BCG) vaccination, commonly used for tuberculosis prevention, has shown some protective effect against Buruli Ulcer. BCG vaccination is recommended in endemic areas as part of the overall prevention strategy.