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Objective To find the relative prevalence of lepra reactions among leprosy patients attending Dermatology out-patient department, the pattern of reactions in different types of leprosy and histopathological features of reaction. Methods The study was an institution-based, longitudinal study. A total 316 leprosy cases attended the Dermatology out-patient department (OPD) of a tertiary care hospital in Eastern India. Results Out of 316 leprosy patients, 58 (18.4%) were diagnosed to have lepra reactions and relative prevalence of type 1 and type 2 reaction was 10.4% and 7.9%, respectively. Among 58 patients, 50 fulfilled the inclusion criteria and were considered for final evaluation. Lepra reactions were common in patients over 30 years of age. There was a high male preponderance and the male to female ratio was 4.5:1. More than 60% of the patients belonged to the below poverty line. Farmers and laborers were more affected. Almost 62% of the patients were literates but most of them had primary education only. Type 1 reaction was more common in BT patients (50%), whereas type 2 reaction were more commonly seen in LL patients (32%). Erythema and swelling of the skin lesions, neuritis and edema of hands and feet were common features of type 1 reaction. Fresh crops of tender evanescent nodules, joint pain, neuritis and fever were common in type 2 reaction. Classical histopathological features were present in all the 50 slides examined. In type 1 reaction patients, lymphocytic infiltration (96%), dermal edema (93%), epithelioid cells (78%) and Langhans type giant cells (15%) were the common histological findings. Edema and foamy macrophages were seen in all cases of type 2 reaction patients. However, polymorphonuclear leucocytes and vasculitis were seen in 21 (95%) and 16 (73%) patients, respectively. Conclusion Lepra reactions, both type 1 and 2, occur in about 20% of leprosy patients. Early detection is warranted to avoid complications. [ABSTRACT FROM AUTHOR]