The clinical feature of the pre-ulcerative stage of the disease are painless nodules, usually occurring singly on the legs or forearms and in theory they are the best target for all therapies.
Nodule
The lesion starts as a small subcutaneous swelling which is barely palpable but not visible. It gradually increases in size until the skin is slightly raised. The nodule is firm with a regular margin and is attached to skin but is not attached to the deep fascia.As the lesion enlarges it involves the deep fascia and then extends in this layer . At this stage the edges are less distinct owing to an intervening layer of normal tissue. The skin overlying the lesion tends to desquamate,leaving a shiny surface which often appears darker than normal. Later the skin over the centre of the lesion loses its pigmentation, becomes necrotic, and eventually ulcerates. In some lesions a small central vesicle develops, which may be broken to exude a small amount of clear fluid. The burst vesicle may progress to an ulcer or it may heal.
BURULI: In this disease it is important to recognize the right moment for starting with a Phage Therapy treatment.
FIGURE 1. Buruli ulcer.Top: Early nodular lesion.
Center/bottom:Deep and undermined ulcerative lesion with necrotic borders, before and after medical treatment plus local surgery including skin grafting.
This figure appears in color at www.ajtmh.org.
