The neuropathic foot in leprosy: a narrative review of the prevention of ulcers and disability

Leprosy remains a disabling neglected tropical disease in which peripheral nerve damage turns the foot into an insensate, deformed and ulcer-prone structure. This narrative review synthesizes the evidence published between 2015 and 2024 on the mechanisms, risk factors and preventive strategies for plantar ulceration and grade 2 disability in the neuropathic foot of leprosy, organized into five thematic axes. The pooled prevalence of plantar ulcer is around 34% in people with foot anaesthesia and 7% among all people affected by leprosy, and grade 2 disability affects roughly one fifth to one third of newly detected cases depending on the setting. Sensory loss, motor paralysis of the intrinsic muscles and foot drop shift plantar pressure toward the metatarsal heads and the calcaneus. Self-care programmes, appropriate footwear, offloading and surgical resection of plantar bony prominences reduce ulceration and recurrence, although most of this evidence is observational or comes from small trials. Delayed detection and the weak integration of foot care into leprosy services sustain disability. The findings support early neurological assessment, structured self-care, footwear provision, offloading and integrated disability prevention within leprosy control programmes, together with a research agenda of comparative studies specific to the leprosy foot rather than extrapolation from the diabetic foot.