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Buruli ulcer

Nature Reviews Disease Primers volume 11, Article number: 89 (2025) Cite this article

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Abstract

Buruli ulcer is a slowly progressive necrotizing disease of the skin caused by Mycobacterium ulcerans, recognized by WHO as a neglected tropical disease. Around 2,000 cases are reported annually, but underdiagnosis and under-reporting probably obscure the true burden. A major advance in the understanding of Buruli ulcer pathogenesis was the discovery that mycolactone, a lipid-like exotoxin secreted by M. ulcerans, inhibits the Sec61 translocon, driving tissue destruction and immune suppression. M. ulcerans is an opportunistic environmental pathogen; however, its mechanisms of transmission remain unclear in most regions. PCR is the current gold standard for diagnosis, but its cost and technical demands limit use in resource-limited settings. Treatment is available with an oral regimen of rifampicin plus clarithromycin for 8 weeks, but further research is in progress to explore alternative drugs, optimized dosing and duration, and improved affordability. Adjunctive wound care, management of paradoxical reactions and rehabilitation, including physiotherapy and psychosocial support, are essential components of Buruli ulcer management. Future efforts should focus on elucidating transmission pathways to inform prevention, developing rapid diagnostics, refining and adapting drug regimens for diverse clinical presentations and patient groups, and advancing wound care. Strengthening healthcare worker training and integrating Buruli ulcer control with that of other skin diseases will enhance accessibility to early diagnosis and treatment, prevent disabilities and deformities, and reduce stigma, ultimately ensuring better quality of life for affected individuals worldwide.

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Fig. 1: Historical events and milestones in Buruli ulcer control.
Fig. 2: Global distribution of Buruli ulcer.
Fig. 3: The mechanism of action of mycolactone.
Fig. 4: Histopathology of Buruli ulcer lesions.
Fig. 5: Clinical spectrum of Buruli ulcer.

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Acknowledgements

The authors thank the individuals affected by Buruli ulcer for their contribution in Box 3.

Author information

Authors and Affiliations

  1. Department of Tropical Medicine and Infectious Disease, Celia Scott Weatherhead School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA

    Rie R. Yotsu

  2. Department of Dermatology, National Center for Global Health and Medicine, Tokyo, Japan

    Rie R. Yotsu

  3. Discipline of Microbes Infection & Immunity, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK

    Rachel E. Simmonds

  4. Department of Parasitology, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon-Accra, Ghana

    Dziedzom K. de Souza

  5. Kumasi Centre for Collaborative Research, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

    Richard Odame Phillips & Yaw Ampem Amoako

  6. School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana

    Richard Odame Phillips & Yaw Ampem Amoako

  7. Division of Infectious Diseases, Department of Medicine, University of Texas at Tyler School of Medicine, Tyler, TX, USA

    Shashikant Srivastava

  8. Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler, Tyler, TX, USA

    Shashikant Srivastava

  9. Department of Malaria and Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland

    Kingsley Asiedu

  10. Centre Pasteur du Cameroun, Yaoundé, Cameroon

    Sara Eyangoh

  11. Department of Infectious Diseases and Immunology, Austin Health and University of Melbourne, Melbourne, Australia

    Paul D. R. Johnson

  12. Swiss Tropical and Public Health Institute, Allschwil, Switzerland

    Gerd Pluschke

  13. University of Basel, Basel, Switzerland

    Gerd Pluschke

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  1. Rie R. Yotsu
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Contributions

Introduction (R.R.Y., R.E.S. and R.O.P.); Epidemiology (R.R.Y., R.E.S., P.D.R.J., S.E., K.A. and G.P.); Mechanisms/pathophysiology (R.R.Y., R.E.S., G.P. and S.E.); Diagnosis, screening and prevention (R.R.Y., R.E.S., D.K.deS., P.D.R.J. and G.P.); Management (R.R.Y., R.E.S., D.K.deS., P.D.R.J., Y.A.A., R.O.P. and S.S.); Quality of life (R.R.Y., Y.A.A., R.O.P. and P.D.R.J.); Outlook (all authors).

Corresponding author

Correspondence to Rie R. Yotsu.

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The authors declare no competing interests.

Peer review

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Nature Reviews Disease Primers thanks R. Gozlan, B. C. De Jong and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Informed consent

The authors affirm that patient participants provided informed consent for publication of their experiences in Box 3. The authors affirm that human research participants provided informed consent for publication of the images in Fig. 5.

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Yotsu, R.R., Simmonds, R.E., de Souza, D.K. et al. Buruli ulcer. Nat Rev Dis Primers 11, 89 (2025). https://doi.org/10.1038/s41572-025-00672-9

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