What is the management of nodular prurigo?

From the Guidelines

Management of nodular prurigo should start with identifying and treating any underlying conditions, and for immediate symptom relief, potent topical corticosteroids such as clobetasol propionate 0.05% ointment should be applied to affected areas twice daily for 2-4 weeks, with occlusion if necessary to enhance penetration, as recommended by recent guidelines 1.

Key Considerations

• Identifying and treating underlying conditions such as atopic dermatitis, renal disease, or liver disease is crucial in managing nodular prurigo.
• Potent topical corticosteroids are the first line of treatment for symptom relief.
• Intralesional corticosteroid injections can be used for resistant nodules.
• Antihistamines like hydroxyzine or cetirizine can help control itching, particularly at night.
• Systemic treatments like oral thalidomide, cyclosporine, or methotrexate may be necessary for more severe cases.
• Newer targeted therapies like dupilumab have shown promise for refractory cases.
• Phototherapy with narrowband UVB can also be effective in managing nodular prurigo.

Treatment Approach

• Start with potent topical corticosteroids and intralesional corticosteroid injections for symptom relief.
• Use antihistamines to control itching, particularly at night.
• Consider systemic treatments for more severe cases.
• Use phototherapy with narrowband UVB as an alternative or adjunct treatment.
• Educate patients about the chronic nature of the condition and the importance of treatment adherence.

Important Considerations

• Breaking the itch-scratch cycle is crucial in managing nodular prurigo.
• Patients should keep nails short, avoid hot showers, use emollients regularly, and consider behavioral therapy techniques.
• Patient education and support are essential for successful management of nodular prurigo.
• Recent guidelines recommend a multi-faceted approach to managing nodular prurigo, including treatment of underlying conditions, symptom relief, and patient education 1.

From the Research

Management of Nodular Prurigo

• Nodular prurigo is a chronic inflammatory skin disease characterized by highly pruritic nodular lesions, and its management has been less than satisfactory with conventional therapies such as systemic antihistamines and topical steroids 2.
• Phototherapy, including narrow-band ultraviolet B (NB-UVB) phototherapy, has been shown to be an effective treatment for recalcitrant nodular prurigo, offering long-term benefits in the majority of patients 2, 3.
• A systematic review of evidence-based treatments for prurigo nodularis found that topical agents, including corticosteroids, calcineurin inhibitors, calcipotriol, and capsaicin, conveyed some beneficial effect, while photo- and photochemotherapy achieved good partial response rates 4.
• Other treatment options for prurigo nodularis include thalidomide, cyclosporine, methotrexate, pregabalin, amitriptyline, paroxetine, fluvoxamine, and neurokinin-1 receptor antagonists, although higher-powered studies and additional randomized controlled trials are needed to evaluate their safety and efficacy 4, 5.
• Non-systemic forms of treatment, including topical corticosteroids, topical steroid-sparing agents, and phototherapy, are first-line treatments for prurigo nodularis, with phototherapy likely being effective but having a high risk of relapse 6.

Treatment Options

• Topical corticosteroids: varying levels of positive response in patients, more effective when used in combination or under occlusive dressing 6.
• Phototherapy: likely effective, but high risk of relapse 6.
• Narrow-band ultraviolet B (NB-UVB) phototherapy: effective treatment for recalcitrant nodular prurigo, offering long-term benefits in the majority of patients 2, 3.
• Thalidomide: demonstrated good symptom response, but needs higher-powered studies and additional randomized controlled trials to evaluate safety and efficacy 4.
• Cyclosporine and methotrexate: demonstrated benefit in combined studies, but needs higher-powered studies and additional randomized controlled trials to evaluate safety and efficacy 4.