Prurigo Nodularis
Prurigo nodularis is a condition involving itchy hard nodules on the skin.
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Amanda Selk
30.1 Introduction Prurigo nodularis is a condition involving itchy hard nodules on the skin and occurs most commonly in adults. It can affect men and women of any age.
30.2 Clinical Presentation Often multiple lesions are present (Fig. 30.1). The distribution of lesions is often symmetric, and they commonly first appear on the arms and legs [1]. Patients often have an atopic history [2]. Prurigo nodularis occurs in 5% of patients with human immunodeficiency virus (HIV), especially in those with low CD4 counts [3]. Affected individuals often complain of intense itching.
Treatment can include topical or intralesional steroids [1]. When steroids fail, lesions may respond to treatment with calcineurin inhibitors or UV phototherapy [1]. There is also randomized controlled trial (RCT) evidence supporting the use of topical calcipotriol ointment [4]. Daily systemic antihistamines are also an important component in treatment. In cases of intractable itching, topical capsaicin has been used [1]. Case series have been published promoting the use of pregabalin or gabapentin to treat
30.3 Treatment Treatment is often multimodal and needs to address both the itching and healing of the lesions [1]. The itch-scratch cycle that occurs is often difficult to treat.
Fig. 30.1 Prurigo nodularis: multiple itchy hard nodules on the skin. They are excoriated as a result of constant pruritus. Courtesy of Professor Jacob Bornstein
A. Selk (*) Women’s College Hospital, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada © Springer International Publishing AG, part of Springer Nature 2019 J. Bornstein (ed.), Vulvar Disease, https://doi.org/10.1007/978-3-319-61621-6_30
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itch that is unresponsive to other treatments [1]. In very resistant cases, some small series of patients have been treated with thalidomide, cyclosporine, and methotrexate [5–7]. It is very important to stop the itch-scratch cycle which can involve daily antihistamines, keeping nails short, wearing gloves, etc. [1]. The use of sedating antihistamines a few hours before bed can help with nighttime itching. Cooling agents are sometimes used for relief such as those with menthol or camphor or simply the application of cold compresses [8]. In general, prurigo nodularis is a disease that recurs after treatment, and complete resolution of lesions is uncommon [1]. Prurigo Nodularis: Breaking the Myths
• Prurigo nodularis is a rare cause of vulvar pruritus. • It consists of symmetric distribution of hard nodules on the vulva but also on the arms and legs. • The pruritus is intractable to many treatments. Among the various therapeutic options that have been described are topical or intralesional steroids, calcineurin inhibitors, UV phototherapy, topical calcipotriol (a vitamin D derivative) ointment, systemic antihistamines, topical capsaicin, oral pregabalin, gabapentin, thalidomide, cyclosporine, or methotrexate. Cooling agents with menthol or camphor or cold compresses have also been used.
References 1. Tsianakas A, Zeid
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