Clofazimine in Erythema Nodosum leprosum: where do we stand?

We read with interest the recent publication by Pai et al. entitled "Erythema Nodosum Leprosum (ENL) treated with additional Clofazimine -A case series." 1 The authors present four cases of ENL managed with prednisolone in combination with clofazimine.We commend the authors for their meticulous documentation of the presented cases.However, we respectfully disagree with their approach to clofazimine utilization and their assertion that published evidence supporting clofazimine in ENL is limited.Considering this, we would like to take this opportunity to engage in a discussion on the relevant literature available regarding the use of clofazimine in ENL.A higher level of evidence supports the use of clofazimine in ENL, with several randomized controlled trials (RCTs) contributing to this body of knowledge.A Cochrane review on interventions in ENL by Van Veen et al. included 13 randomized control trials (RCT) involving 445 participants. 2Two trials showed significant long-term benefits with clofazimine treatment compared to thalidomide (fewer recurrences) or prednisolone (more treatment success). 3,4][7] In a small RCT involving 20 patients with ENL, the efficacy of clofazimine and pentoxifylline in combination with prednisolone was compared. 8Pentoxifylline demonstrated initial efficacy, while sustained efficacy was observed in the clofazimine group.In another clinical trial by Kar et al. the efficacy of a combination of prednisolone with clofazimine was compared to a combination of prednisolone with thalidomide in patients with chronic/recurrent ENL. 9 The study noted improvement in 10 out of 16 cases in the prednisolone with clofazimine group.