Prurigo Nodularis Treatment & Management

  • Author: Daniel J Hogan, MD; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Jul 9, 2010
 

Medical Care

Current available treatments of prurigo nodularis have had mild-to-moderate success at best. Often, combinations of several medications or physical modalities may be used in an attempt to control this process.

Topical, oral, and intralesional corticosteroids have all been used in prurigo nodularis in attempts to decrease inflammation and sense of itching and to soften and smooth out firm nodules. The improvement with corticosteroids is variable, and corticosteroids are sometimes not helpful. Intralesional corticosteroid (usually triamcinolone acetonide) treatment is commonly used in resistant cases of limited extent. Triamcinolone acetonide concentrations as low as 2.5 mg/mL may be effective, although more scarred pruriginous lesions may require higher concentrations. A total dose of 20 mg (8 mL of 2.5 mg/mL) for adults every 3-4 weeks is safe for patients without diabetes mellitus or hypertension. An 8-am serum cortisol test can be performed if concerns exist about adrenal suppression.[16]

Menthol, phenol, pramoxine, capsaicin cream,[17] vitamin D-3 ointment,[18] and topical anesthetics are some other topical agents used to reduce pruritus. Treatment with DuoDerm or other occlusive therapies has been suggested to flatten lesions while at the same time preventing patients from directly scratching nodules.[19]

UV light treatment using UV-B[20] or UV-A plus psoralen may be beneficial for severe pruritus. Consider the adverse effects of prolonged UV exposure before such treatment. Monochromatic 308-nm light therapy may be helpful for recalcitrant lesions,[21] although this modality may be more useful in atopic dermatitis.[22] UV-A1 has also been reported to benefit lichen simplex chronicus and prurigo nodularis.[23]

Antihistamines, anxiolytics, opiate receptor antagonists, and (most recently) thalidomide are oral medications other than steroids used for prurigo nodularis. Thalidomide[24, 25, 26] has been shown to aid in several severe dermatoses, including prurigo nodularis with or without associated HIV disease.[20, 27] Severe teratogenic effects are well known and documented, and all women of childbearing age should be on adequate birth control methods. Patients taking thalidomide have an increased risk of peripheral neuropathy.

For steroid unresponsive patients or those with lesions on thin skin, a few case reports and small studies have shown efficacy of the topical immunomodulators tacrolimus and pimecrolimus.

Anecdotally, gabapentin has been reported to benefit prurigo nodularis.[28] Sedation is the main problem with this generic medication.

Habit reversal therapy for the itch-scratch cycle associated with prurigo nodularis may be helpful and can be administered by dermatology nurses trained in this therapy.[29]

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Surgical Care

Cryotherapy with liquid nitrogen helps reduce pruritus and flatten lesions.[30, 31] This modality can be particularly helpful in upper limb and trunk lesions for patients with diabetes mellitus or in patients with hypertension to minimize adverse effects of intralesional and highly potent topical corticosteroids. Thirty-second thaw cycles with 2-4 treatments are recommended, depending on the size of the lesion. Understanding the risks of scarring and change in pigmentation (especially in darker-skinned individuals) is important. Cryotherapy may be combined with other modalities (eg, intralesional corticosteroids).

Pulsed dye laser therapy may help reduce the vascularity of individual lesions.

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Consultations

Pay special attention to patients with prurigo nodularis. Take a careful history of immune compromise or other internal disease. Refer patients to an internist or a family physician for possible further investigation and examination. Some patients benefit from psychiatric referral once underlying dermatologic and medical disorders have been excluded.[32]

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Activity

Instruct prurigo nodularis patients to minimize touching, scratching, and rubbing affected areas.

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Contributor Information and Disclosures
Author

Daniel J Hogan, MD  Clinical Professor of Internal Medicine (Dermatology), Nova Southeastern University College of Osteopathic Medicine; 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 School of Medicine

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.

Specialty Editor Board

Franklin Flowers, MD  Chief, Division of Dermatology, Professor, Department of Medicine and Otolaryngology, Affiliate Associate Professor of Pediatrics and Pathology, 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.

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.

Jeffrey Meffert, MD  Assistant Clinical Professor of Dermatology, University of Texas School of Medicine at 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.

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.

References

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Prurigo nodularis. Courtesy of Jeffrey Meffert, MD.
Prurigo nodularis. Courtesy of Jeffrey Meffert, MD.
 
 
 
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