Published on 18/03/2015 by admin
Filed under Dermatology
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Christopher Rowland Payne
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Prurigo nodularis (PN) is an excoriated eruption characterized by lichenified nodules. It favors the distal parts of the extensor aspects of the limbs and may be considered a localized form of lichen simplex chronicus.
PN affects all ages and the sex ratio is equal. Pruritus is episodic and disabling. Excoriation is always severe. The eruption is polymorphic. PN has many clinical and histological similarities with eczema. Neural hyperplasia is minimal or absent.
PN usually has an identifiable underlying cause. In half of patients it is due to a cutaneous disorder – usually atopic dermatitis, sometimes gravitational eczema, lichen simplex, nummular eczema, or insect bites, and occasionally subclinical dermatitis herpetiformis or subclinical bullous pemphigoid (known as pemphigoid nodularis). The cause is metabolic in one-third of cases, and in the remainder it is psychological, usually depression, sometimes anxiety or psychosis. The diverse metabolic disorders that cause PN induce itching by a small number of shared mechanisms, most commonly nutritional deficiency, hepatic dysfunction, and uremia, and occasionally thyroid disorder, hypercalcemia, neurological disorder (e.g., stroke), or lymphoma. Nutritional deficiency (the marker of which is reduced iron saturation) usually results from dietary deficiency, such as iron deficiency in women (in which dietary intake is insufficient to compensate for menstrual loss), and sometimes results from malabsorption (more often post-operative than gluten-sensitive) or from gastrointestinal bleeding.
In some patients all three causes (cutaneous, metabolic, and psychological) may be relevant concurrently. Thus, it is not unusual for a particular patient to have more than one underlying drive for itching: for example, PN may be due to atopic dermatitis which has been precipitated and perpetuated by an acute reactive depression and aggravated by concomitant nutritional deficiency (due to the apathetic diet of a lonely person living alone). For a successful outcome in such a patient, the atopic dermatitis, the depression and the diet each need attention. It is not enough just to treat the nodules.
In PN, remission can be expected when there is good patient compliance with symptomatic measures. However, cure is dependent on resolution of the underlying disorder.
The best treatment for PN is holistic. Best therapeutic results are achieved by symptomatic treatment of the cutaneous eruption while concurrently identifying and correcting the underlying cause of the itch. To do this a full medical history, complete physical examination, and a range of simple investigations are needed to determine the driver (or drivers) for the itching, whether metabolic, psychological, or cutaneous.
Symptomatic treatment is very effective. In all patients it is essential to overcome all itching by using full doses of sedating oral antihistamines, such as promethazine 25–75 mg (which is best given 11 hours before rising, rather than at bedtime). Patients may be helped to restrain themselves from excoriation by cutting their nails to the quick, by wearing mittens, or by using occlusive dressings, such as hydrocolloids. Occlusive bandaging or even plaster of Paris casts can be applied in resistant cases. The most potent topical corticosteroids are necessary and should be applied accurately to individual lesions in a cream form or as an impregnated tape (Cordran Tape, Haelan Tape). Intralesional injection of corticosteroids is also helpful (triamcinolone acetonide 40 mg/mL can be injected, 0.1 mL/nodule, and repeated at 6-weekly intervals). Topical capsaicin and/or cryotherapy may be added. When lesions are too numerous to treat topically or by injection, phototherapy with UVB or PUVA may be helpful. In severe and therapy-resistant cases oral thalidomide may be considered.
Treatment of the underlying cause is essential in order to achieve cure. Each specific etiology requires its own specific treatment.
When atopic dermatitis is the cause, treatments aimed at atopic dermatitis are likely to be the most successful. These would include emollients, sedative antihistamines, and potent or very potent topical corticosteroids, sometimes under occlusion.
In PN of metabolic origin, hepatic cases carry the best prognosis: when liver function tests return to normal, a successful outcome can be expected. Nutritional deficiency is common. Although this is often associated with iron deficiency anemia, iron supplements alone are not always helpful. If those deficient of iron are also deficient in other blood-borne nutrients, it is more logical to advise eating 50 g of dark meat daily and 50 g of animal liver each week. Uremia, thyroid disorder, and lymphoma clearly need their own specific treatments.
In patients who scratch for psychological reasons, treatment depends on the underlying disturbance. The most frequent is depression, and this often responds to tricyclic antidepressants, such as dothiepin 75–225 mg nocte or doxepin. Not every case of PN is pruritic, but all are excoriated. Excoriations of marked severity or excoriations without itching may indicate a psychological origin.
Complete blood count, ESR
Blood urea nitrogen, creatinine
Liver function tests
Iron saturation (iron/total iron-binding capacity or iron/transferrin) (ferritin is not as good a test)
Calcium and albumin
Thyroid function tests
Pemphigoid and celiac antibodies
Chest X-ray
Possibly serum IgE
Possibly feces for ova, cysts, and parasites (three specimens)
Possibly HIV serology
Possibly biopsies for direct immunofluorescence to exclude prevesiculobullous forms of dermatitis herpetiformis, pemphigoid, and linear IgA disease
Rowland Payne CME. In: Bernhard JD, eds. Itch – Mechanisms and Management of Pruritus. New York: McGraw-Hill, 1994; 103–19.
Based on a series of 67 patients, the overall patient management of PN is discussed comprehensively.
Rowland Payne CME, Wilkinson JD, McKee PH, Jurecka W, Black MM. Br J Dermatol 1985; 113: 431–44.
The underlying causes of PN are recorded in this paper.
Koblenzer CS. Br J Dermatol 1996; 135: 330–1.
Koblenzer emphasizes the importance of treating the underlying cause of the itching rather than simply trying to suppress the symptoms with cyclosporine or any other drug.
Meyers LN. Int J Dermatol 1989; 28: 275–6.
Four patients with PN responded to weekly application of an occlusive hydrocolloid pad (Duoderm). All lesions resolved, but recurred several weeks later in one patient and several months later in a second. One of these patients responded to application of an occlusive pad and an unspecified tranquilizer. The other again cleared with application of the occlusive pad.
Adhesive occlusive pads physically mitigate excoriation, neutralizing the chief aggravating factor in PN.
Saraceno R, Chiricozzi A, Nistico SP, Tiberti S, Chimenti S. J Dermatolog Treat 2010; 21: 363–6.
Twelve patients were enrolled in this comparison of betamethasone valerate 0.1% tape versus a moisturizing itch-relief cream containing feverfew. Occlusive dressing enhanced the efficacy of the treatment, preventing scratching.
The cure depends upon finding the cause of the itch and treating it. Symptomatic improvement can be achieved with superpotent topical corticosteroids, preferably under an adhesive occlusive pad (e.g., Duoderm), in association with full doses of promethazine 25–75 mg at 8pm.
Stander S, Luger T, Metze D. J Am Acad Dermatol 2001; 44: 471–8.
Thirty-three patients with PN were treated with topical capsaicin (0.025–0.3%) four to six times daily for periods of between 2 weeks and 10 months. Pruritus resolved in all patients within 12 days, but returned in 16 of 33 patients within 2 months of discontinuation of capsaicin.
Stoll DM, Fields JP, King LE Jr. J Dermatol Surg Oncol 1983; 9: 922–4.
Two patients were treated with liquid nitrogen applied with a cotton-tipped applicator for a freeze time of 10 seconds, followed by intralesional injection of triamcinolone acetonide (10 mg/mL) mixed with lidocaine (lignocaine) 0.75%. All lesions resolved after four to eight injections at 4- to 6-week intervals.
Waldinger TP, Wong RC, Taylor WB, Voorhees JJ. Arch Dermatol 1984; 120: 1598–600.
An African-American woman resistant to multiple therapies, including topical corticosteroids, oral hydroxyzine hydrochloride, phototherapy, and tar, was successfully treated with liquid nitrogen.
Cryotherapy to the point of blistering may cause scarring and hypopigmentation, as it did in this patient.
Hans SK, Cho MY, Park YK. J Am Acad Dermatol 1990; 29: 436–7.
Two patients were treated with UVB administered three times a week for 24 to 30 treatments. Itching resolved and most lesions cleared. Residual large lesions were treated with intralesional injection of corticosteroids and with topical PUVA.
Tamagawa-Mineoka R, Katoh N, Ueda E, Kishimoto S. J Dermatol 2007; 34: 691–5.
Once-weekly narrowband ultraviolet B phototherapy notably improved 10 patients with recalcitrant nodular prurigo. At 1-year follow-up only one had relapsed. The other nine continued to derive long-term benefit.
Vaatainen N, Hannuksela M, Karvonen J. Acta Derm Venereol 1979; 59: 544–7.
Fifteen patients with PN responded to trioxsalen baths and UVA. Moderate (seven patients) or good (eight patients) results were achieved in 3 weeks. Itching improved markedly in 4 to 6 days. Initial doses of 0.1–0.2 J/cm2 were given daily, and doses increased by approximately 50% every third day.
Karoven J, Hannuksela M. Acta Derm Venereol 1985; 120: 53–5.
Bath and ointment trioxsalen PUVA was given to 63 patients with nodular prurigo, with good effect in 81%. In most patients the disease relapsed and further treatment was needed to maintain the result. After 1 to 6 years of follow-up, 18% of patients were totally healed.
Divekar PM, Palmer RA, Keefe M. Clin Exp Dermatol 2003; 28: 92–102.
Phototherapy of various types (broadband UVB, bath PUVA, and oral PUVA) was administered to 14 patients with nodular prurigo. The patients were given 19 courses of treatment (nine to 34 visits). Partial improvement occurred in two-thirds, complete remission in three (but two of these had recurrence within 1 year).
Saraceno R, Nistico SP, Capriotti E, de Felice C, Rhodes LE, Chimenti S. Photodermatol Photoimmunol Photomed 2008; 24: 43–5.
Eleven patients were studied. Partial or complete clinical and histological remission occurred in 80% who had weekly monochromatic excimer light (308 nm) for an average of eight sessions.
Hammes S, Hermann J, Roos S, Ockenfels HM. J Eur Acad Dermatol Venereol 2011; 25: 799–803.
Twenty-two patients with PN were treated with either PUVA alone or with a combination of PUVA and excimer UVB. Adding a 308 nm excimer UVB to the treatment of the pruritic nodules speeded up the healing process: 30% less PUVA radiation was needed.
Edmonds EV, Riaz SN, Francis N, Bunker CB. Br J Dermatol 2004; 150: 1216–17.
One patient responded to topical tacrolimus.
Wong SS, Goh CL. Arch Dermatol 2000; 136: 807–8.
A prospective, randomized, double-blind right–left comparison of calcipotriol ointment and betamethasone valerate ointment in the treatment of PN.
Katayama I, Miyazaki Y, Nishioka K. Br J Dermatol 1996; 135: 237–40.
Nine of 11 cases showed a significant clinical response to this new regimen within 4 weeks.
Yoshizawa Y, Kitamura K, Maibach HI. Br J Dermatol 1999; 14: 387–9.
Six of eight patients showed apparent improvement both on clinical scores and laboratory data until 16 weeks after DNCB therapy.
Woo PN, Finch TM, Hindson C, Foulds IS. Br J Dermatol 2000; 143: 215–16.
A patient with recalcitrant nodular prurigo, resistant to topical and intralesional steroids as well as PUVA, responded well to treatment with pulsed dye laser (595 nm).
Winkelmann RK, Connolly SM, Doyle JA, Padilha-Goncalves A. Acta Derm Venereol 1984; 64: 412–17.
Four patients with PN were treated with oral thalidomide, resulting in rapid resolution of itching and subsequent resolution of nodules. Doses of 100–300 mg daily were required. Three of the four had elevated IgE levels that decreased during treatment. In one patient the lesions recurred after discontinuation of the treatment, but responded again to further oral thalidomide. Two patients achieved long-term remission.
Ferrandiz C, Carrasocsa JM, Just M, Bielsa I, Ribera M. Dermatology 1997; 195: 359–61.
Four patients with PN were started on thalidomide and subsequently treated with narrowband UVB for up to 37 treatments. One patient who relapsed after 5 months was controlled anew with a further course of UVB without thalidomide.
Maurer T, Poncelet A, Berger T. Arch Dermatol 2004; 140: 845–9.
Eight HIV-infected patients with prurigo were treated with thalidomide 100 mg daily. After the first month, patients were randomized to receive 100 mg or 200 mg daily and the dose was adjusted if side effects developed. All had a more than 50% reduction in itching within an average of 3.4 months. Seven of eight had a greater than 50% reduction in skin lesions within an average of 5 months. Thalidomide peripheral neuropathy developed in three patients.
Andersen TP, Fogh K. Dermatology 2011; 223: 107–12.
In a retrospective study of 42 patients treated with thalidomide, the majority experienced clinical improvement. Side effects were the most common reason for discontinuation, most frequent being peripheral neuropathy and sedation.
Taefehnorooz H, Truchetet F, Barbaud A, Schmutz JL, Bersztejn AC. Acta Derm Venereol 2011; 91: 344–5.
Kanavy H, Bahner J, Korman NJ. Arch Dermatol 2012; 148: 794–6.
Fatigue, constipation, peripheral neuropathy, and even acute generalized eruptive pustulosis are frequent and/or important and limiting adverse effects of this treatment. Thalidomide is hazardous to give to women of childbearing potential because of the potential for severe birth defects. In the author’s own center’s experience, six of 10 patients with nodular prurigo improved with thalidomide. Adverse effects occurred in all 10 and led to discontinuation of treatment in six. Adverse effects from thalidomide are common, serious, and unpredictable. Thalidomide cannot be recommended as a safe treatment for PN in anything but exceptional circumstances.
Berth-Jones J, Smith SG, Graham-Brown RAC. Br J Dermatol 1995; 132: 795–9.
Two women with PN improved markedly while taking oral cyclosporine 3–4.5 mg/kg daily, but neither cleared completely.
Siepmann D, Luger TA, Stander S. J Dtsch Dermatol Ges 2008; 6: 941–6.
In 13 of 14 prurigo patients there was a signification response to monotherapy with oral cyclosporine.
As well as the usual risks of the renal complications, reversible ascending motor neuropathy has also been reported from cyclosporine given for nodular prurigo.
Feldmeyer L, Werner S, Kamarashev J, French LE, Hofbauer GF. Br J Dermatol 2012; 166: 461–2.
Gencoglan G, Inanir I, Gunduz K. Dermatol Ther 2010; 23: 194–8.
Four patients with PN responded to gabapentin.
Lear JT, English JS, Smith AG. Br J Dermatol 1996; 134: 1151.
Two patients with nodular prurigo responded to azathiaprine 50 mg twice daily.
Horiuchi Y, Bae S, Katayama I. J Drugs Dermatol 2006; 5: 363–5.
Three cases of uncontrollable PN were treated with a combination of 300 mg/day roxithromycin and 200 mg/day tranilast. Complete and/or marked regression of PN was observed within 4 to 6 months.
Gip L. Dermatologica 1984; 169–260.
Rowland Payne CME. Br J Dermatol 1988; 118–36.
Unemori P, Leslie KS, Maurer T. Arch Dermatol 2010; 146: 682–3.
Two cases of HIV associated PN dramatically improved within 2 weeks of initiating twice daily oral raltegravir, 400 mg.
Samuels N, Sagi E, Singer SR, Oberbaum M. Am J Clin Hypn 2011; 53: 283–92.
A single case with a successful outcome.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
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