Non-Systemic Medication for the Treatment of Prurigo Nodularis: A Systematic Review.

Prurigo nodularis (PN) is a skin disease characterized by firm, itchy, erythematous lesions. Treatment consists of systemic and non-systemic modes of therapy. Non-systemic forms of treatment are first-line and include topical corticosteroids, topical steroid-sparing agents, and phototherapy. The objective was to review the efficacy of non-systemic treatment used to treat PN. A systematic search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with PROSPERO (CRD42023412012). The search consisted of keywords and Medical Subject Heading (MeSH) terms and translated to Ovid MEDLINE, Embase, and Scopus. Google Scholar was also searched for the first 200 articles. Article quality of evidence was scored using GRADE criteria. The search yielded 1151 results; 37 met criteria for inclusion. There were 14 studies on phototherapy, and 11 studies on topical corticosteroids, most of which were also combined with topical antihistamines, antipruritics, and/or phototherapy. There were 2 studies each on topical antipruritics used in isolation, vitamin D analogues, and intralesional triamcinolone acetonide. There was 1 study each on topical pimecrolimus, tacrolimus, 2% dinitrochlorobenzene, cryotherapy, acupuncture, and the Paul Gerson Unna boot. Most were case reports and case series, although 2 randomized controlled trials on phototherapy and topical pimecrolimus were included. Corticosteroids had varying levels of positive response in patients and appeared more effective when used in combination or under occlusive dressing. Phototherapy is likely effective, but the risk of relapse is high. Cryotherapy may also be a lesion-directed agent to circumvent challenges to adherence and avoidance of systemic medication.

[Update on the treatment of chronic prurigo]. / Update zur Therapie der chronischen Prurigo.

Chronic prurigo is an inflammatory dermatosis defined by the presence of chronic pruritus and single to multiple symmetrically distributed pruriginous lesions such as nodules, papules, and plaques. Various dermatological, systemic, neurological, and/or psychiatric diseases are associated with chronic prurigo. The care of these patients is very complex due to the multifactorial character and also because of the sometimes very pronounced consequences such as an impairment of quality of life with sleep disorders. Furthermore, there are no approved therapies. The current guideline-based treatment recommendations include topical application of steroids, capsaicin, calcineurin inhibitors, phototherapy, and systemic use of gabapentinoids, µ­opioid receptor antagonists, immunosuppressants, or dupilumab. Results from randomized controlled trials and case series on new therapies including biologics (e.g., nemolizumab) and Janus kinase inhibitors are promising. This article provides an overview of currently available treatment options and discusses the latest data on the efficacy of future therapies.

Non-Atopic Chronic Nodular Prurigo (Prurigo Nodularis Hyde): A Systematic Review of Best-Evidenced Treatment Options.

BACKGROUND: Chronic nodular prurigo (CNPG) is a chronic, inflammatory skin disease, characterized by intense and debilitating pruritus. The pathophysiology is not fully understood, and the condition is difficult to treat with no targeted therapies. The aim of this systematic review was to review the evidence of therapies for non-atopic CNPG and conduct a meta-analysis of the results. SUMMARY: We conducted a systematic review of the literature concerning effect of treatment for non-atopic CNPG. Due to few randomized controlled trials (RCTs) and case series, the literature was unfortunately too sparse to conduct a meta-analysis of the results. Instead, we thoroughly report important data from the three existing RCTs and 6 case studies with more than 15 patients. Evaluated therapies include nemolizumab, aprepitant, topical therapy with hydrocortisone and pimecrolimus, thalidomide, UVA phototherapy, pregabalin, and naltrexone. Included RCTs and case studies all had a heterogeneous methodology making direct comparison almost impossible. KEY MESSAGES: There is sparse evidence for the currently used therapies for non-atopic CNPG. Several RCTs on new therapies are running or in the pipeline, hopefully providing new, effective, and targeted treatment possibilities for CNPG patients both with and without an atopic predisposition.

Attenuation of actinic prurigo eruptions with Polypodium leucotomos supplementation.

Actinic prurigo is a rare pruritic photodermatosis. We report the use of Polypodium leucotomos extract in an 11-year-old female patient with actinic prurigo, resulting in a significant attenuation of her disease without development of adverse effects to date. Polypodium leucotomos exerts a pleiotropic immunomodulatory and antioxidant effect by shifting the balance from pro- to an antiinflammatory cytokine environment. This counteracts the effects of UV-induced cellular damage characteristic of photodermatoses.

Prurigo excoriée treated with low dose naltrexone.

A 53-year-old woman presented with a 25-year history of acne excoriée and prurigo excoriée. Her symptoms began in 1988 coinciding with her husband's death from a brain tumour when she was 27. The pruritus affected her quality of life and disturbed her sleep. She had scarring on her face and body resulting from persistent scratching. The pruritus proved refractory to treatment despite a multi-modal treatment approach including multiple topicals, phototherapy and systemic agents such as isotretinoin, antibiotics, anxiolytic agents and neuromodulators. She was extremely frustrated that various treatments had been ineffective at controlling the itch-scratch cycle. She was commenced on low dose naltrexone (LDN), 3 mg nocte, and she became itch free within a few weeks. She reports that the LDN has had a beneficial impact on her quality of life.

Oral Alitretinoin for Patients with Refractory Prurigo.

Background: prurigo is a chronic skin disorder associated with a history of chronic pruritus. The pathogenesis of prurigo is largely unknown and the treatment of prurigo is unsatisfactory and challenging. Conventional systemic treatments may be beneficial; however, their possible side effects and possible transient efficacy is still a problem. We aimed to present the clinical course and effect of treatment with alitretinoin on patients with prurigo nodularis initially treated with conventional treatments like oral antihistamine, cyclosporine, and phototherapy. Methods: all the patients had prurigo nodularis refractory to conventional treatment. Their medical records included demographic features, past medical history, duration of disease, and treatment modalities; and the clinical courses of the patients were reviewed for this retrospective study. We evaluated patient pruritus and skin lesions for the duration. Results: we present reports involving 10 patients with refractory prurigo. All the patients in our cases were treated with oral alitretinoin after previous treatments and reported the improvement of skin lesions and pruritus within 2 weeks to 3 months. Conclusions: we suggest that oral alitretinoin may be an effective and well tolerated treatment option for patients with intractable prurigo. Further clinical studies are warranted to confirm the long-lasting efficacy and safety of alitretinoin for treating patients with prurigo.

Thalidomide for the treatment of chronic refractory prurigo nodularis.

Prurigo nodularis (PN) is a highly pruritic skin condition that is caused by chronic scratching. It occurs in patients with chronic itch and is characterized by multiple hyperkeratotic papules and nodules. The pathogenesis of PN is unclear, but involves a complex interplay of numerous pathways including neurogenic and inflammatory factors. As such, PN is very difficult to treat and patients are often refractory to multiple medications before finding a treatment that is effective. We present a woman with a 20-year history of exuberant prurigo nodularis who failed multiple therapies, including dapsone, azathioprine, mycophenolic acid, prednisone, topical steroids, and phototherapy. She only obtained significant relief of chronic pruritus and lesion flattening with thalidomide 100mg daily. Thalidomide is an antipruritic and anti-inflammatory agent that has shown to be very effective in treating a variety of dermatologic conditions. However, its use today is limited by concerns for its teratogenic and neuropathic side effects. With strict adherence to medication protocols, these adverse effects can be minimized. As such, thalidomide should be considered for patients with refractory dermatologic conditions.

Generalized eruptive keratoacanthoma with vitiligo followed by the development of prurigo nodularis: A case report and published work review.

Herein, we report a unique case of generalized eruptive keratoacanthoma (GEKA) in a 47-year-old Chinese man presenting with extensive pruritic papules and nodules accompanied by oral lesions. He also had a 2-year history of vitiligo and long-term experience of working outdoors. Biopsies were consistent with keratoacanthoma . Interestingly, prurigo nodularis (PN) was found in histopathology at 1-year follow up. To our knowledge, this is the first report describing a case of GEKA with oral lesions complicated with vitiligo and developed with PN.

Treatment of prurigo with methotrexate: a multicentre retrospective study of 39 cases.

BACKGROUND: Prurigo is a common primary pruritic condition. Treatment is challenging. Methotrexate (MTX) is effective for the treatment of pruriginous dermatoses, but its use in prurigo has been little studied. OBJECTIVES: To investigate the efficacy and safety of MTX in the treatment of difficult-to-treat prurigo. METHODS: Patients from six university dermatology departments treated with MTX between 2006 and 2016 for difficult-to-treat prurigo (i.e. with failure to conventional therapies) were included in this retrospective multicentre study. Patients with other pruritic dermatoses were excluded. Clinical efficacy was recorded after 3, 6 and 12 months of treatment: (i) subjective efficacy, that is, evaluation of the pruritus by the patient and (ii) objective efficacy, that is, assessment of cutaneous lesions by the physician: complete or almost complete remission (CR) (healing of lesions), partial remission (PR) (incomplete improvement of lesions) or failure (no improvement or worsening). The overall response rate (ORR) included CR and PR. RESULTS: Thirty-nine patients with previous failure of topical steroids, H1-antihistamine drugs or phototherapy were included. The median weekly dose of MTX was 15 mg (range 5-25 mg). The median follow-up was 16 months (2-108). The mean time between onset of MTX and objective efficacy was 2.4 ± 1.2 months and the mean duration of response was 19 ± 15 months. The ORR was 91% at 3 months [n = 36, CI 95% (81.2-100.8%), CR 44%], 94% at 6 months [n = 32, CI 95% (85.7-102.2%), CR 56%] and 89% at 12 months [n = 28, CI 95% (77.4-100.6%), CR 57%]. Seven patients stopped MTX because of failure, and five because of the discovery of hepatocarcinoma (n = 1), elevated transaminases (n = 1), infectious pneumonitis (n = 1) or gastrointestinal symptoms (n = 2). CONCLUSION: Methotrexate is a therapeutic option in difficult-to-treat prurigo.

Prurigo nodularis: retrospective study of 13 cases managed with methotrexate.

BACKGROUND: Prurigo nodularis (PN), or nodular prurigo, is a chronic, debilitating, inflammatory skin disease. It can be very difficult to manage, and represents a challenge for the physician. Methotrexate (MTX) is a safe folic acid antagonist widely used in the management of inflammatory skin diseases such as psoriasis. Weekly administration of 7.5-20 mg methotrexate (low-dose methotrexate, LD-MTX) represents an attractive treatment option, and could therefore find a place in the management of PN. AIM: To evaluate the efficacy of LD-MTX as a treatment option for PN. METHODS: Thirteen patients who had failed to respond to conventional therapies such as topical steroids, phototherapy and antipruritic agents were treated with LD-MTX. The mean age of the patients was 75.83. Objective symptoms (Prurigo Nodularis Area and Severity Index; PNASI) and subjective symptoms (Pruritus Numeric Rating Scale; PNRS) were recorded. Treatment consisted of one subcutaneous injection of MTX 7.5-20 mg once weekly for a minimum of 6 months. Adjuvant application of emollients and topical steroids was maintained where needed. RESULTS: There was remission or marked improvement (decrease in both PNRS or PNASI of > 75%) in 10 cases, a trend to improvement in 2 cases and relapse in 1 case after treatment discontinuation. CONCLUSIONS: LD-MTX may allow improvement of PN in some patients, with long-lasting remission.

Successful treatment of chronic intractable itching using oral pregabalin in a patient with diabetes and systemic prurigo nodularis: a case report of an iliopsoas muscle abscess.

A 73-year-old Japanese man developed chronic intractable itching due to prurigo nodularis. High-dose glucocorticoid ointment failed, and the treatment resulted in poor glycemic control. Repeated scratching caused hematogenous bacterial dissemination via cutaneous injuries, resulting in the formation of iliopsoas and spinal epidural abscesses that required long-term antibiotic treatment. Pregabalin was administered to treat the pruritus, and a considerable improvement was observed. A reduction in the dose and intensity of the topical corticosteroids improved the patient's glycemic control, resulting in the complete resolution of the abscesses. Pregabalin significantly improved the patient's pruritus and decreased the risk of infection.

UVB 308-nm excimer light and bath PUVA: combination therapy is very effective in the treatment of prurigo nodularis.

BACKGROUND: Prurigo nodularis (PN) is a chronic inflammatory skin disease with nodular itching lesions. UV therapy--both PUVA and NUVB--are known to clear up PN temporarily due to the antipruritic effect of UV light. However, relapse after treatment is common in PN, which means that either long-term therapy is necessary or the treatment protocols have to be optimized to minimize side-effects. OBJECTIVE: The aim of this study was to evaluate the effect that combining bath PUVA and targeted UVB 308 nm excimer radiation has on recalcitrant nodular prurigo. METHODS: In a prospective trial, 22 patients with PN were treated with either PUVA alone or with a combination of PUVA and excimer UVB. The end point was complete or almost complete remission of PN. RESULTS: Adding a 308-nm excimer UVB to the treatment of the pruritic nodules sped up the healing process; 30% less PUVA radiation was needed. CONCLUSION: The combination of PUVA and excimer UVB in PN appears to be very efficacious. Reducing psoralen UVA doses by 30% offered long-term benefits in phototherapy of chronic recalcitrant diseases like PN.

A 14-year-old girl with multiple, firm, dome-shaped eroded nodules and itching on the limbs.

The standard treatment of prurigo nodularis (PN) includes antihistamines, ultraviolet light, and topical and systemic corticosteroids; unfortunately, PN is notoriously resistant to the conventional therapy. Herewith is described one case of PN, which was initialized with herose as the first-line therapy resulting in complete clinical clearance. Results of follow-up examinations from 2005 to 2009 showed no evidence of recurrence. Findings indicate that herose monotherapy is a potentially promising therapeutic options for PN.

An occlusive dressing containing betamethasone valerate 0.1% for the treatment of prurigo nodularis.

INTRODUCTION: Prurigo nodularis is a distressing condition characterized by the presence of multiple nodules associated with intense pruritus. OBJECTIVE: To assess the clinical efficacy and safety of betamethasone valerate 0.1% tape and a moisturizing itch-relief cream in prurigo nodularis. METHODS: Twelve patients were enrolled in this pilot comparison of betamethasone valerate 0.1% tape versus a moisturizing itch-relief cream containing feverfew. The study period was 4 weeks. Clinical evaluation was performed weekly. RESULTS: Eleven subjects completed the 4 weeks of therapy. The mean visual analogue scale (VAS) for pruritus at baseline was 8.75 for both sides of the body. The side treated with betamethasone valerate 0.1% tape showed a higher clinical response (VAS score at week 4: 3.9; p < 0.005) compared with the side treated with moisturizing itch-relief cream (VAS score at week 4: 5.6; p < 0.005). CONCLUSION: Both treatments were effective. However, the occlusive dressing enhanced the efficacy of the treatment, preventing scratching.

Excimer laser vs. clobetasol propionate 0·05% ointment in prurigo form of atopic dermatitis: a randomized controlled trial, a pilot.

BACKGROUND: Recent findings have established the 308-nm xenon chloride excimer laser (EL) as a new option in the area of ultraviolet (UV) B phototherapy. As this laser enables high radiant exposure of narrowband UVB and precise targeting of affected skin, it appears to be a promising treatment for the prurigo form of atopic dermatitis (AD). OBJECTIVES: To investigate the efficacy and safety of the EL compared with clobetasol propionate (CP) in the prurigo form of AD. METHODS: In a prospective randomized within-patient controlled study, 13 patients with a prurigo form of AD were randomized to receive EL on one side and topical CP on the other side. Laser treatment was performed twice a week for 10 weeks. Clinical responses were evaluated using Physician Assessment of Individual Signs, Physician Global Assessment, Patient Global Assessment and photographic documentation. Histopathological changes were evaluated and duration of remission was monitored during a 6-month follow-up period. RESULTS: Both treatments resulted in a significant improvement of all outcome measures after 10 weeks of treatment. During follow up, the EL showed more improvement compared with CP. Histopathology demonstrated marked decrease of epidermal thickness and inflammatory infiltrate at the EL-treated sites. No significant side-effects occurred. CONCLUSIONS: This study suggests that the EL can safely and effectively be used in the treatment of the prurigo form of AD. For the long term, the EL might be a good alternative to topical corticosteroids and an option in case of therapy-resistant patients.

Therapeutic hotline: Treatment of prurigo nodularis and lichen simplex chronicus with gabapentin.

Psychocutaneous conditions are frequently encountered in dermatology practice. Prurigo nodularis and lichen simplex chronicus are two frustrating conditions that are classified in this category. They are often refractory to classical treatment with topical corticosteroids and antihistamines. Severe, generalized exacerbations require systemic therapy. Phototherapy, erythromycine, retinoids, cyclosporine, azathiopurine, naltrexone, and psychopharmacologic agents (pimozide, selective serotonin reuptake inhibitor antidepressants) were tried with some success. Here five cases with lichen simplex chronicus and four cases with prurigo nodularis, who responded well to gabapentin, are presented.

[Prurigo]. / Les prurigos.

Prurigo is a medical term which includes several clinical, pathological and etiologic entities. Diagnostic and therapeutic management is different depending on if we face acute prurigo or chronic prurigo. Acute prurigo is almost always linked to parasites or insects. Chronic prurigo can be linked to dermatologic diseases or may reveal internal pathologies. Complementary exams we should ask for are focused on these diseases. Idiopathic chronic prurigo, without underlying disease, is the most frequent one. It needs regular survey, as it can reveal cutaneous or internal diseases after months or even years. Treatment of prurigo is treatment of the underlying disease. Symptomatic treatment against pruritus, topic or systemic, must be added.