Treatment

In Australia, many cases of M. ulcerans infection are managed with oral antibiotics alone. Surgery may be required for extensive disease as an adjunct to antibiotics.

A recommended antibiotic regimen for M. ulcerans infection is:

Other regimens that have been used are rifampicin plus either moxifloxacin or ciprofloxacin. For patients who cannot take rifampicin, an alternative regimen is moxifloxacin plus clarithromycin. Intravenous amikacin is reserved for severe cases and is rarely used.

Clinical deterioration during antibiotic treatment can be caused by a paradoxical reaction to treatment rather than antibiotic failure.

Surgery may be required in some patients. The procedure consists of excision of the ulcer and either primary closure or grafting; adjunctive antibiotic treatment reduces the need for wide excision and allows preservation of deep structures. Although small lesions can be cured with resection alone, relapse may occur if antibiotics are not used. With larger lesions, antibiotics and surgery are often used sequentially, with 4 to 8 weeks of antibiotics used before excision.

Conservative surgical debridement of necrotic tissue is likely to facilitate healing (see Surgical wound debridement). Repeated debridement may be needed.

Healing of M. ulcerans lesions is slow and may continue for up to 12 months after completion of antibiotic therapy if skin defects are large, particularly when the diagnosis has been delayed. Inform patients that the ulcer will continue to heal after antibiotic therapy is stopped.

Adjuvant heat therapy may reduce the risk of relapse after resection for patients who cannot have antibiotic therapy. A small case series from Africa found that direct application of heat to the ulcer for several hours each day for up to 8 weeks reduced relapse¹ .