The standard for treatment Buruli ulcer disease (BUD) used to be surgery but the WHO now advises streptomycin (S, 15 mg/kg daily, intramuscularly) and rifampicin (R,10 mg/kg daily) along with surgery. This preliminary advice was based on observations in 21 patients with pre-ulcerative lesions of BUD, who were given daily SR treatment for varying periods of time. In patients treated with SR for at least 4 weeks, M. ulcerans could no longer be cultured from excised lesions. SR has been introduced without a formal evaluation or comparison with other treatments have been conducted or published, but the impression is that this treatment is beneficial and may cure BUD without additional surgical management.

This study protocol evaluates the hypothesis that early, limited lesions of BUD(pre-ulcerative or ulcerated lesions, ≤ 10 cm maximum diameter), can be healed without recurrence using antimycobacterial drug therapy, without the need for debridement surgery.

In endemic regions in Ghana, patients will be actively recruited and followed if ≥ 5 years of age, and with early (i.e., onset < 6 months) BUD.

• consent by patients and / or care givers / legal representatives
• clinical evaluation, and by
• analysis of three 0.3 cm punch biopsies under local anaesthesia.
• disease confirmation: dry reagent-based polymerase chain reaction (DRB-PCR IS2404)
• randomization: either SR for 8 weeks, or 4 weeks of SR followed by R and clarithromycin (C)
• stratification: ulcerative or pre-ulcerative lesions.

Biopsies will be processed for histopathology, DRB-PCR-, microscopy, culture, genomic, and sensitivity tests. Lesions will be assessed regularly for progression or healing during treatment. Drug toxicity monitoring includes blood cell counts, liver enzymes and renal tests; and ECG and audiographic tests. Primary endpoint: healing without recurrence at 12 months follow-up after start of treatment Secondary endpoint: reduction in lesion surface area and/or clinically assessed improvement on completion of treatment, averting the need for debridement surgery.

Recurrences will be biopsied for confirmation, using PCR, histopathology, and culture. Sample size: 200 patients, with 2x74 evaluable patients to be randomized; 80% power to detect a difference of 20 % in recurrence-free cure 12 months after start of treatment between the two groups (60 versus 80%). A Data Safety and Monitoring Board will make interim analyses.