Bigger may not always be better: giant borderline tuberculoid leprosy lesion.

A 30-year-old male presented with a huge skin lesion on his back of 7 months duration. He had taken paucibacillary multi-drug therapy (PB MDT) privately for the last 2 months. Swelling and redness had developed 1 month after starting the treatment. He had also developed a small satellite lesion near the lower end of this large lesion. There was no history of fever. Examination revealed a very large, raised, erythematous, anaesthetic plaque with dry surface and scaling on his back.The plaque covered more than two-thirds of his back and measured 35 cm and 32 cm at its longest and widest points, respectively (Figure 1).The edges were infiltrated and had prominent scaling, more so along the lower edge, near which smaller satellite lesions were seen. Systemic examination and routine haematological investigations were normal. Histological evaluation of the lesion revealed upper dermal granulomas of epitheloid cells, lymphocytes and a few Langhan’s giant cells. There was mild oedema in the upper dermis. Ziehl–Neebon stain did not reveal any acid-fast bacilli. He was diagnosed as a case of borderline tuberculoid leprosy in upgrading reaction. Tablet prednisolone 40 mg daily was added to the PB MDT, and tapered over the next 10 months.The lesion did not change during 6 months of MDT. It was only after taking 10 months of PB MDT that any appreciable changes occurred in the lesion. After that, it began to flatten, but the PB MDT had to be continued for 1 year and 8 months for reasonable regression to be visible.