eMedicine Specialties > Dermatology > Environmental

Prurigo Nodularis: Differential Diagnoses & Workup

Author: Daniel J Hogan, MD, Clinical Professor of Internal Medicine (Dermatology), NOVA Southeastern University; Investigator, Hill Top Research, Florida Research Center
Coauthor(s): Siobahn M Bower, MD, Internal Medicine Resident, Creighton University; Sharron M Mason, MD, Staff Physician, Department of Internal Medicine, University of Kansas School of Medicine; Stephen H Mason, MD, Assistant Professor of Dermatology, Medical College of Georgia
Contributor Information and Disclosures

Updated: Oct 23, 2009

Differential Diagnoses

Acne Keloidalis Nuchae
Knuckle Pads
Actinic Keratosis
Lymphocytoma Cutis
Amyloidosis, Nodular Localized Cutaneous
Lymphomatoid Papulosis
Atypical Fibroxanthoma
Mastocytosis
Chondrodermatitis Nodularis Helicis
Milker's Nodules
Cutaneous Horn
Molluscum Contagiosum
Cutaneous T-Cell Lymphoma
Multicentric Reticulohistiocytosis
Dermatofibroma
Mycobacterium Marinum Infection of the Skin
Dermatologic Manifestations of Gastrointestinal Disease
Papulonecrotic Tuberculids
Dermatologic Manifestations of Hematologic Disease
Pilomatrixoma
Dermatologic Manifestations of Renal Disease
Pretibial Myxedema
Hyperkeratosis Lenticularis Perstans (Flegel Disease)
Sarcoidosis
Insect Bites
Squamous Cell Carcinoma
Keratoacanthoma
Xanthomas

Other Problems to Be Considered

Mastocytosis (urticaria pigmentosa)
Pemphigoid nodularis10,11
Pilomatrixoma (benign calcifying epithelioma, calcifying epithelium of Malherbe)

Workup

Laboratory Studies

  • Perform a CBC count and a chemistry panel, including liver function tests (LFTs), to help exclude underlying hematologic malignancies, renal failure, and hepatic diseases.

Procedures

  • Obtaining skin biopsy samples of prurigo nodularis lesions for histologic examination and/or cultures may be indicated to exclude squamous cell carcinoma (particularly the keratoacanthoma type) and infections (especially deep fungal, atypical mycobacterial).
  • Patch testing to exclude contact sensitivity may be considered, particularly with coexisting dermatitis.

Histologic Findings

The histologic features of prurigo nodularis12 include a hyperkeratotic epidermis with acanthosis and parakeratosis. Rete ridges are elongated and irregular with a dense dermal infiltrate consisting of neutrophils, eosinophils, histiocytes, and monocytes.13 Also notable in the dermis are thickened nerve fibers and fibrosis with thickened collagen bundles.

Thickened nerve fibers are dilated on electron microscopy. Schwann cells show vacuolization and degeneration with no detectable mitochondria. Axons and Schwann cells both show hyperproliferation.12,14

More on Prurigo Nodularis

Overview: Prurigo Nodularis
Differential Diagnoses & Workup: Prurigo Nodularis
Treatment & Medication: Prurigo Nodularis
Follow-up: Prurigo Nodularis
Multimedia: Prurigo Nodularis
References
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References

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  39. Szeidemann Z, Shanabrough M, Leranth C. Hypothalamic Leu-enkephalin-immunoreactive fibers terminate on calbindin-containing somatospiny cells in the lateral septal area of the rat. J Comp Neurol. Aug 7 1995;358(4):573-83. [Medline].

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Further Reading

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Keywords

prurigo nodularis, Hyde prurigo nodularis, picker’s nodules, lichen simplex chronicus, prurigo nodularis type, atypical nodular form of neurodermatitis circumscripta, lichen corneus obtusus, PN

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Contributor Information and Disclosures

Author

Daniel J Hogan, MD, Clinical Professor of Internal Medicine (Dermatology), NOVA Southeastern University; Investigator, Hill Top Research, Florida Research Center
Daniel J Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Contact Dermatitis Society, and Canadian Dermatology Association
Disclosure: Nothing to disclose.

Coauthor(s)

Siobahn M Bower, MD, Internal Medicine Resident, Creighton University
Siobahn M Bower, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Sharron M Mason, MD, Staff Physician, Department of Internal Medicine, University of Kansas School of Medicine
Disclosure: Nothing to disclose.

Stephen H Mason, MD, Assistant Professor of Dermatology, Medical College of Georgia
Stephen H Mason, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Society for Dermatologic Surgery, Skin Cancer Foundation, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Medical Editor

Franklin Flowers, MD, Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, University of Florida College of Medicine
Franklin Flowers, MD is a member of the following medical societies: American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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