<p>Treatment-resistant prurigo nodularis: challenges and solutions</p>

Abstract

Prurigo nodualris (PN) is a chronic condition with highly pruritic, hyperkeratotic papules or nodules arising in the setting of chronic pruritus. While PN may serve as a phenotypic presentation of several underlying conditions such as atopic dermatitis, chronic kidney disease-related pruritus, and neurological diseases, it represents a distinct clinical entity that may persist despite the removal of the underlying cause, if one is identified. Neuronal proliferation, eosinophils, mast cells, and small-fiber neuropathy play a role in the production of pruritus in PN, although the exact mechanism has not yet been established. Identifying an underlying cause, if present, is essential to prevent recurrence of PN. Due to often present comorbidities, treatment is typically multimodal with utilization of topical and systemic therapies. We performed a PubMed/MEDLINE search for PN and present a review of recent developments in the treatment of PN. Treatment typically relies on the use of topical or intralesional steroids, though more severe or recalcitrant cases often necessitate the use of phototherapy or systemic immunosuppressives. Thalidomide and lenalidomide can both be used in severe cases; however, their toxicity profile makes them less favorable. Opioid receptor antagonists and neurokinin-1 receptor antagonists represent two novel families of therapeutic agents which may effectively treat PN with a lower toxicity profile than thalidomide or lenalidomide.

An Emollient Containing Aquaphilus dolomiae Extract is Effective in the Management of Xerosis and Pruritus: An International, Real-World Study

“…It is also noteworthy that the emollient was also very effective against pruritic xerosis associated with prurigo nodularis of Hyde, a chronic skin condition characterized by intense pruritus. Prurigo nodularis of Hyde is very difficult to treat and, although emollients are recommended as base therapy to prevent xerosis, effective management usually involves the use of topical or interlesional steroids and systemic immunosuppressive drugs [36]. To our knowledge, no previous clinical studies-using a robust study design and validated assessment tools-have been published demonstrating the effectiveness of other emollients for the treatment of persistent itch in patients post scabies treatment and for the intense pruritus associated with prurigo nodularis of Hyde.…”

Keratin 17 is induced in prurigo nodularis lesions

“…As far as we are concerned, there has been no standard criterion of treatment for itch until now. Treatment typically relies on the use of topical or intralesional steroids, although more severe or recalcitrant cases require novel therapeutic agents for treatment according to the underlying factors of PN [39]. Calcipotriol ointment, a synthetic form of vitamin D, acts to inhibit skin keratinocyte cell proliferation and enhance cell differentiation in the skin of patients with psoriasis, and downregulation of K17 is vital for its effect [40].…”

<p>Treatment-resistant prurigo nodularis</p>

“…Kowalski et al describe various treatment approaches to achieve better outcomes in treatment-resistant prurigo nodularis in an article entitled, “Treatment-resistant prurigo nodularis: challenges and solutions.”1 Many excellent approaches are suggested, but the issue of nonadherence to topical therapies may be an overlooked issue commonly contributing to “treatment-resistance.” Often, in the face of “resistant” disease, patients may be prescribed more complicated or risky treatment regimens that make adherence even more difficult. Such strategies may not be the most effective ones when poor adherence underlies seemingly treatment-resistant prurigo nodularis.…”