What is the initial treatment for prurigo nodularis?

Initial Treatment for Prurigo Nodularis

Start with potent topical corticosteroids such as clobetasol propionate 0.05% applied to the nodules as first-line therapy for prurigo nodularis. 1

First-Line Topical Therapy

• Potent topical corticosteroids are the cornerstone of initial management, with clobetasol propionate 0.05% being the preferred agent for prurigo nodularis lesions 1, 2
• Treatment duration should be limited to avoid side effects—specifically, treatment beyond 2 consecutive weeks is not recommended, and total dosage should not exceed 50 mL/week to prevent HPA axis suppression 2
• Topical corticosteroids appear more effective when used under occlusive dressing, which enhances penetration into the hyperkeratotic nodules 3
• Intralesional triamcinolone acetonide can be injected directly into individual nodules for recalcitrant lesions 3, 4

Adjunctive First-Line Options

• Topical menthol preparations may be added to provide counter-irritant effects that help relieve the intense pruritus characteristic of prurigo nodularis 1
• Topical calcineurin inhibitors (tacrolimus or pimecrolimus) can be used as steroid-sparing agents, particularly for long-term management or facial lesions 3, 5
• Avoid topical capsaicin, crotamiton cream, and calamine lotion as they lack significant antipruritic effect in prurigo nodularis 1

Cryotherapy as Alternative First-Line

• Cryotherapy (5-10 seconds per session, given in two cycles) demonstrates superior efficacy compared to clobetasol propionate alone, with 100% of patients achieving 75-100% nodule clearance versus only 27% with topical steroids 6
• This lesion-directed approach circumvents adherence challenges and avoids systemic medication exposure 3
• Cryotherapy was preferred by 63.6% of patients over topical corticosteroids in comparative studies 6

Second-Line Systemic Therapy (If Topical Treatment Fails After 2-4 Weeks)

• Non-sedating antihistamines should be initiated if topical therapy is inadequate: fexofenadine 180 mg, loratadine 10 mg, or cetirizine 10 mg daily 1
• Consider combining H1 and H2 antagonists (e.g., fexofenadine plus cimetidine) for enhanced antipruritic effect 1
• Phototherapy (narrowband UVB or broadband UVB) provides symptomatic relief but carries high relapse risk 1, 3

Third-Line Options for Refractory Cases

• Gabapentinoids are the preferred third-line agents for neuropathic pruritus: pregabalin 25-150 mg daily or gabapentin 900-3600 mg daily 1, 5
• Antidepressants (paroxetine, fluvoxamine, mirtazapine) may reduce pruritus intensity through central mechanisms 1
• Aprepitant (neurokinin-1 receptor antagonist) has demonstrated efficacy in reducing pruritus 1, 5
• Immunosuppressants such as cyclosporin or thalidomide are reserved for severe, treatment-resistant cases 5, 4

Critical Diagnostic Consideration

• Always investigate for underlying systemic diseases including renal disease, liver disease, lymphoma, or iron deficiency that may be causing or exacerbating prurigo nodularis before attributing it to primary skin disease 1

Monitoring Timeline

• Reassess treatment efficacy after 2-4 weeks; if nodules worsen or fail to improve, escalate to the next treatment tier 1
• For intolerable pruritus despite initial therapy, consider treatment interruption and more aggressive management 1