Buruli ulcer is an infectious disease characterized by the development of painless open wounds. The disease is limited to certain areas of the world, most cases occurring in Sub-Saharan Africa and Australia. The first sign of infection is a small painless nodule or area of swelling, typically on the arms or legs. The nodule grows larger over days to weeks, eventually forming an open ulcer. Deep ulcers can cause scarring of muscles and tendons, resulting in permanent disability.

Buruli ulcer is caused by skin infection with bacteria called Mycobacterium ulcerans. The mechanism by which M. ulcerans is transmitted from the environment to humans is not known, but may involve the bite of an aquatic insect or the infection of open wounds. Once in the skin, M. ulcerans grows and releases the toxin mycolactone, which blocks the normal function of cells, resulting in tissue death and immune suppression at the site of the ulcer.

The World Health Organization (WHO) recommends treating Buruli ulcer with a combination of the antibiotics rifampicin and clarithromycin. With antibiotic administration and proper wound care, small ulcers typically heal within six months. Deep ulcers and those on sensitive body sites may require surgery to remove dead tissue or repair scarred muscles or joints. Even with proper treatment, Buruli ulcer can take months to heal. Regular cleaning and dressing of wounds aids healing and prevents secondary infections.

In 2018, WHO received 2,713 reports of Buruli ulcer globally. Although rare, it typically occurs in rural areas near slow-moving or stagnant water. The first written description of the disease is credited to Albert Ruskin Cook in 1897 at Mengo Hospital in Uganda. Fifty years later, the causative bacterium was isolated and identified by a group at the The Alfred Hospital in Melbourne. In 1998, WHO established the Global Buruli Ulcer Initiative to coordinate global efforts to eliminate Buruli ulcer. WHO considers it a neglected tropical disease.

Treatment

Buruli ulcer is treated through a combination of antibiotics to kill the bacteria, and wound care or surgery to support the healing of the ulcer. The most widely used antibiotic regimen is once daily oral rifampicin plus twice daily oral clarithromycin, recommended by the World Health Organization. Several other antibiotics are sometimes used in combination with rifampicin, namely ciprofloxacin, moxifloxacin, ethambutol, amikacin, azithromycin, and levofloxacin.  A 2018 Cochrane review suggested that the many antibiotic combinations being used are effective treatments, but there is insufficient evidence to determine if any combination is the most effective. Approximately 1 in 5 people with Buruli ulcer experience a temporary worsening of symptoms 3 to 12 weeks after they begin taking antibiotics. This syndrome, called a paradoxical reaction, is more common in those with larger ulcers and ulcers on the trunk, and occurs more frequently in adults than in children. The paradoxical reaction in Buruli ulcer is thought to be due to the immune system responding to the wound as bacteria die and the immune-suppressing mycolactone dissipates.

Small or medium-sized ulcers typically heal within six months of antibiotic treatment, whereas larger ulcers can take over two years to fully heal. Given the long healing times, wound care is a major part of treating Buruli ulcer. The World Health Organization recommends standard wound care practices: covering the ulcer to keep it moist and protected from further damage; regularly changing wound dressings to keep the ulcer clean, removing excess fluid, and helping prevent infection. Treatment sometimes includes surgery to speed healing by removing necrotic ulcer tissue, grafting healthy skin over the wound, or removing scar tissue that can deform muscles and joints. Specialized wound dressings developed for non-infectious causes of ulcer are occasionally used for treating Buruli ulcer, but can be prohibitively expensive in low-resource settings.

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