What is the treatment for prurigo nodularis?

Treatment for Prurigo Nodularis

The treatment of prurigo nodularis requires a stepwise approach starting with potent topical corticosteroids and potentially advancing to systemic therapies based on response. 1, 2

First-Line Treatments

• Topical therapies:
  • Potent topical corticosteroids such as clobetasol propionate 0.05% are first-line treatment for prurigo nodularis, though treatment should be limited to avoid side effects (maximum 50 mL/week for no more than 2 consecutive weeks) 3, 1
  • Intralesional corticosteroids can be effective for individual, resistant nodules 2
  • Topical calcineurin inhibitors may be used as steroid-sparing agents 4
  • Topical menthol preparations may provide counter-irritant effects that help relieve pruritus 5
  • Cryotherapy has shown good results in some studies, with 75-100% nodule clearance and was preferred by patients over topical clobetasol in one comparative study 1

Second-Line Treatments

• Antihistamines:

  • Non-sedating antihistamines (fexofenadine 180 mg, loratadine 10 mg) or mildly sedative agents (cetirizine 10 mg) should be tried before sedating antihistamines 5
  • Consider combination of H1 and H2 antagonists (e.g., fexofenadine and cimetidine) for enhanced effect 5
  • Sedative antihistamines (e.g., hydroxyzine) should be limited to short-term or palliative settings due to potential side effects 5

• Phototherapy:

  • Narrowband UVB (NB-UVB) or broadband UVB (BB-UVB) can provide symptomatic relief 5
  • Consider maintenance phototherapy to prevent relapse after initial improvement 5

Third-Line Treatments

• Neuromodulatory agents:

  • Gabapentinoids (pregabalin 25-150 mg daily, gabapentin 900-3600 mg daily) can be effective for neuropathic pruritus 5, 4
  • Antidepressants including paroxetine, fluvoxamine, and mirtazapine may help reduce pruritus intensity 5, 6

• Immunomodulators:

  • Cyclosporine has demonstrated benefit in reducing both nodules and pruritus 4
  • Thalidomide has shown good symptom response but has significant side effect concerns 4
  • Methotrexate may be beneficial though evidence is limited 4

• Other systemic options:

  • Aprepitant (80 mg daily), a neurokinin-1 receptor antagonist, has shown efficacy in reducing pruritus 5, 4
  • Naltrexone and butorphanol may be considered for refractory cases 5

Treatment Considerations

• Avoid ineffective treatments:

  • Crotamiton cream is not recommended as it lacks significant antipruritic effect 5
  • Topical capsaicin and calamine lotion are not recommended for generalized pruritus 5

• Address underlying conditions:

  • Always investigate for potential underlying systemic diseases (e.g., renal disease, liver disease, lymphoma, iron deficiency) that may be causing or exacerbating prurigo nodularis 5, 7

• Treatment challenges:

  • Prurigo nodularis is often difficult to treat and may require multiple therapeutic approaches 6
  • Patients typically experience persistent, severe pruritus (average intensity 7.8/10) lasting >6 months in 82% of cases 6
  • Most patients require 2-4 physician visits per year for ongoing management 6

Monitoring and Follow-up

• Reassess treatment efficacy after 2 weeks; if reactions worsen or do not improve, proceed to next treatment option 5
• For grade 3 (intense, widespread, constant pruritus limiting self-care) or intolerable grade 2 pruritus, consider treatment interruption and more aggressive management 5
• Monitor for side effects of treatments, particularly with long-term topical steroid use (skin atrophy, telangiectasia) and systemic therapies 3