Buruli ulcer

Role of specific antibiotics in Mycobacterium ulcerans (Buruli ulcer) management

Provisional guidelines

Documenting the disease and monitoring response through treatment

The forms for recording treatment and follow-up can be found in Annexes 2–4.

New cases

Role of the health worker

Health workers who prescribe the antibiotic combination for the management of M. ulcerans disease should carefully document all clinical decisions, procedures, clinical improvement and any adverse effects.

Role of the laboratory

Depending on the laboratory facilities available in the particular area or country, any of the following or a combination may be used:

  • direct smear examination,
  • culture,
  • polymerase chain reaction (PCR),
  • histopathology.

For ulcerative lesions, for example, at the start of antibiotic treatment, swabs should be taken from the undermined edges of the ulcer for direct smear examination, culture and PCR. Specimens (swabs or tissue fragments) should also be taken at the end of antibiotic treatment (if the lesion has not healed or surgery is indicated) to analyse the response to the treatment.

For non-ulcerative lesions, before the start of antibiotic treatment, a small punch biopsy (3 mm diameter) should be taken if possible from the estimated centre of the lesion for microbiological (direct smear examination, culture and PCR) and histopathological analyses. During or at the end of antibiotic treatment, if surgery becomes necessary, specimens should again be taken for laboratory analyses.


Where possible and practical, documentation of the response to treatment should include serial tracing of lesions and measurement of the size of lesions at regular intervals, possibly weekly. For oedematous lesions, the circumference of the limb should be measured at three fixed points at weekly intervals. For purposes of comparison, measure the unaffected limb at the same points at the start of and throughout the treatment.


Photography is a powerful and convincing way of recording the disease and the results of antibiotic and surgical treatments. For oedematous lesions on the limbs, the photographs should be taken in a position so that the affected and the unaffected limbs can be compared. For all forms of the disease, it is also important that consecutive photographs should be taken from an equidistant position to permit reasonable comparison.

Recurrent cases

These should be noted and documented in the same way as new cases.