Prurigo Nodularis Workup

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

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.

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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.

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Histologic Findings

The histologic features of prurigo nodularis[12] 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]

Highly characteristic for prurigo nodularis is the presence of thick, compact orthohyperkeratosis; irregular epidermal hyperplasia or pseudoepitheliomatous hyperplasia; focal parakeratosis or superficial epithelial necrosis; hypergranulosis; fibrosis of the papillary dermis with vertically arranged collagen fibers; increased number of fibroblasts and capillaries; a superficial, perivascular and/or interstitial inflammatory infiltrate of lymphocytes, macrophages and, to a lesser extent, eosinophils and neutrophils. Correlation of clinical and histological findings is necessary to reliably distinguish between prurigo nodularis and lichen simplex chronicus,[15] although both disorders may coexist in the same patient and both are a reaction to rubbing or scratching the skin.

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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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