Nodular prurigo L28.1

Authors: Prof. Dr. med. Peter Altmeyer, Timon Renggli

Co-Autor: Hadrian Tran

All authors of this article

Last updated on: 19.07.2021

Dieser Artikel auf Deutsch

Synonym(s)

Chronic Prurigo; Chronic Prurigo of Nodular Type; Eccema verrucosum callosum; Eccema verrucosum callosum nodulare; lichen corneus disseminatus; lichen obtusus corneus; Lighting specifications circonscrits nodulaires chroniques; maculopapulosis lichenificatio; neurodermatitis nodosa; nodular lichenification; nodular prurigo; nodular prurigo (Hyde's prurigo); obtuse papulae; Picker`s nodule; Prurigo nodular; tuberosis cutis pruriginosa; Urticaria perstans chronica papulosa; Urticaria perstans verrucosa

History
This section has been translated automatically.

The disease was first described by Haraway in the USA in 1880. Subsequently, in France, Lailler, Brocq, de Beurmann, Hallopeau described the disease casuistically. Brocq describes it under the title Lichen corneus obtusus. In the German literature Fabry, Kreibich Hübner and Brill are listed among the authors. Hyde & Montgomery proposed the name prurigo nodularis in 1909, which later became accepted.

Definition
This section has been translated automatically.

Very rare, chronic, polyetiological systemic disease characterized by numerous, large, violently pruritic (or also painful) plaques and nodules, which is considered to be the maximum form of prurigo simplex subacuta (or nodular variant of lichen simplex chronicus).

Characteristic of this disease is an almost unbreakable cycle of itching/pain - uncontrollable scratching - from lesional scratching artifacts with reactive skin changes (increased density of substance P-positive nerves) as well as itching/pain flaring up again (Tsianakas A et al. 2016).

Clinically, malignant tumor diseases (e.g., lymphogranulomatosis of the skin; cutaneous T-cell lymphoma) should be excluded. Renal and hepatic insufficiency, diabetes mellitus and gluten sensitivity should be clarified (Suárez C et al. 1984).

A highly chronic course over several years (decades) is predictable and must be taken into account when planning therapy.

Etiopathogenesis
This section has been translated automatically.

Unknown.

A sensorimotor peripheral polyneuropathy induced by multiple factors, often subclinical, is discussed (Hughes JM et al. 2020). It has been shown that reduced intraepidermal nerve fiber density (IENFD) is present in the skin lesions of prurigo nodularis (see also small fiber neuropathy). To date, the effects and associations of gluten sensitivity on this disorder remain poorly understood and researched.

The pathogenesis of prurigo nodularis also involves a form of "neuronal sensitization", whereby the itch/pain-processing neurons are triggered and activated, thereby maintaining an "itch-scratch cycle".

An inflammatory response in the skin and neuronal plasticity also play a role. Histopathologically, there are changes in the nerve fibers in the skin as well as inflammatory cells in the dermis. The itch/pain in this disease may be triggered by release of tryptase, interleukin 31 (IL-31), prostaglandins, eosinophil cationic protein (ECP) and neuropeptides by inflammatory cells, mast cells and nerve fibers.

Recent studies show that up to 50-fold increased production of interleukin-31 mRNA is detectable in prurigo nodes. The studies on patients with atopic dermatitis and prurigo nodularis, suggest that interleukin-31 secreted by activated CD4-positive T cells is a major trigger of itch/pain in these diseases. Thus, interleukin-31 is already referred to as the "itch cytokine".

IL-31 receptor A is most highly expressed in the sensory neurons of the spinal ganglia of the spinal cord. Similarly, interleukin-31 activates signal transducers of the JAK-STAT pathway (JAK1 and JAK2), which in turn can induce itch.

Manifestation
This section has been translated automatically.

Mainly occurring in middle-aged and older women.

Localization
This section has been translated automatically.

Sacral region (50%), abdomen (40%), bilateral extensor sides of the extremities, face, soles of the feet and palms of the hands remain free.

Clinical features
This section has been translated automatically.

Disseminated, usually symmetrically arranged, dome-like raised, 0.3 - 2.0 cm in size, rough, initially slightly or more reddened with prolonged persistence, reddish-brown to dirty grey, excruciatingly itchy (itching may also turn into pain) roundish, firm papules and nodules. The itching is continuous or alternates between periods of relative calm and unbearable itching.

The nodules are usually sharply demarcated, maintaining a defined distance from each other. They do not confluence. This results in a striking topographical pattern. The nodules are frequently excoriated by deliberately placed scratching artifacts, the lesions being scooped out to the deep corrium with the fingernails or suitable objects.

There is a tendency for keratotic or verruciform surface structures.

The surrounding skin usually shows no scratch marks and is largely unchanged. Other signs of underlying skin disease (e.g. evidence of atopic or psoriatic diathesis) are absent.

Histology
This section has been translated automatically.

Pronounced, clumsy acanthosis with irregular elongation of the mostly bulbously raised reteleasts. Clear proliferation of the pelvic epithelia. Thus there is an overall aspect of pseudoepitheliomatous hyperplasia. Severe orthohyperkeratosis with focal parahyperkeratosis. Wide capillaries are visible in the papillary stratum and in the upper dermis. In addition, there are predominantly vascular, but also diffuse, rather sparse lymphohistiocytic infiltrates, which are occasionally mixed with eosinophilic leukocytes. Plasma cells and neutrophil leukocytes are also found in erosions. In most cases a clear fibrosis of the dermis is visible, with collagen bundles running perpendicular to the epidermis. Repeated evidence of schwannoma-like neural hyperplasia(Pautrier's neuroma).

Differential diagnosis
This section has been translated automatically.

Prurigo simplex subacuta (no nodules, only nodules, identical itching)

Prurigo form of atopic eczema (detectable signs of atopic eczema)

Lichen planus verrucosus (to be verified histologically, mostly lower leg; search for other lichen planus lesions!)

Prurigo form of the bullous pemphigoid (DIF to be clarified, no nodules)

Multiple eruptive keratoakanthomas (eruptive beginning, itching is absent, typical clinic of keratoakanthomas with central honey plug)

General therapy
This section has been translated automatically.

Therapeutic results of all known therapeutic measures are unsatisfactory. In almost all patients, topical cortisone preparations fail after initial slight success, and antihistamines are also ineffective.

Cooperation with a psychologist or a psychiatrist is necessary to improve the (reactively) depressive attitude of the patient. Especially in prurigo nodularis patients suffer more from anxiety, depression and have more suicidal thoughts.

A therapeutic approach with tricyclic antidepressants can be helpful in coping with the disease.

A new approach is the treatment with nemolizumab, which showed good results in a phase II trial at Münster University Hospital in 2020 as part of the drug approval process. The compound has recently been approved (Williams KA et al. 2021).

External therapy
This section has been translated automatically.

Short-term highly potent external glucocorticoids such as 0.1% mometasone ointment (e.g. Ecural) or 0.05% clobetasone cream (e.g. Dermoxin) under occlusion.

If without effect, multiple, potwise, intralesional application of triamcinolone (draw up 10 mg Volon A together with 1-2 ml 1% scandicaine, take your time when injecting, use a thin needle).

Sublesional application is easier but useless. In addition, there is a risk of fat tissue atrophy in women!

There have been reports of success with ablative laser systems, see below. Here, the principle of "eradication" of the lesion with subsequent scar healing is effective.

Radiation therapy
This section has been translated automatically.

In case of atopically superimposed clinical picture try phototherapy (UVB or UVA1), balneophototherapy, PUVA therapy, systemic or local (as balneophotochemotherapy).

Internal therapy
This section has been translated automatically.

Sedating antihistamines such as hydroxyzine (e.g. Atarax) with 1-3 tablets/day p.o. Dimetinden (e.g. Fenistil) 2 times/day 1 tablet p.o. or Clemastin (e.g. Tavegil) 2 times/day 1 tablet p.o. are therapeutics of first choice.

In case of therapy resistance: therapy with methotrexate - 15-20mg/week s.c. ( off-label use)

Alternative: Ciclosporin A (3.0-5.0 mg/kg bw/day).

Alternative: Trial of thalidomide 200 mg/day ( off-label use).

Alternative: Further therapeutic options are amitriptyline or gabapentin (= anticonvulsant; e.g. Gabapentin STADA) initially 1 time/day 300 mg, increase to 3 times/day 300 mg p.o.; further dose increase if necessary, with intact renal function (control of renal parameters!), by 300 mg/day each time up to a maximum dose of 3600 mg/day in 3 ED.

Alternative: pregabalin (Lyrica®) and the neurokinin-1 receptor antagonist aprepitant.

Alternative: Dupilumab; in case of absolute resistance to therapy, a curative trial with Dupilumab is warranted. Very good success has been described with this therapy (Calugareanu A et al. 2019). (According to our own findings, this therapeutic approach is superior to any previously applied therapeutic measure!)

Experimental: Nemolizumab: In clinical trials is the interleukin31 receptor blocker Nemolizumab, a first-in-class humanized monoclonal antibody, with which very good clinical results have been achieved. Nemolizumab targets the IL-31 receptor alpha, which blocks IL-31 signaling.

Operative therapie
This section has been translated automatically.

Cryosurgery (2-fold cryocycle in open spray procedure), electrocoagulation or laser therapy( dye laser).

Note: Surgical measures lead tolocal destruction with consecutive scarring (including destruction of dermal nerve structures). Such eradications remain (in a systemic disease) always only localized measures.

In this respect, reports on a general healing of prurigo nodularis after surgical measures are to be evaluated with scepticism!

Progression/forecast
This section has been translated automatically.

Highly chronic course characterized by considerable resistance to therapy. Spontaneous healing is very rare. The single-cell florescence heals with shallow scarring.

Note(s)
This section has been translated automatically.

Although the clinical picture of the (very rare) nodular Prurigo can be well differentiated from the nodular Prurigo simplex subacuta, this differentiation is often not made in international literature. However, our own experience confirms the entity of the clinical picture in several cases.

Literature
This section has been translated automatically.

  1. Ahmed E et al (1997) Cyclosporine treatment of nodular prurigo in a dialysis patient. Br J Dermatol 136: 805-806
  2. Calugareanu A et al (2019) Dramatic improvement of generalized prurigo nodularis with dupilumab. J Eur Acad Dermatol Venereo 33:e303-e304.
  3. Fostini AC et al (2013) Prurigo nodularis: an update on etiopathogenesis and therapy. J Dermatolog Treat 24:458-462
  4. Hughes JM et al (2020) Association between prurigo nodularis and Etiologies of Peripheral
  5. Neuropathy: Suggesting a Role for Neural Dysregulation in Pathogenesis.
  6. Medicines (Basel) 7:4.
  7. Hyde JN, Montgomery FH (1909) A practical treatise on disease of the skin for the use of students and practitioners. Lea & Febiger, Philadelphia, pp. 174-175.
  8. Lotti T et al (2008) Prurigo nodularis and lichen simplex chronicus. Dermatol Ther 21:42-46
  9. Ruzicka T et al: Anti-interleukin-31 receptor A antibody for atopic . N Engl J Med 376: 826-35

  10. Siepmann D (2008) Antipruritic effect of cyclosporine microemulsion in prurigo nodularis: results of a case series. JDDG 6: 941-946
  11. Spring P et al (2014) Prurigo nodularis: retrospective study of 13 cases managed with methotrexate. Clin Exp Dermatol 39:468-473
  12. Stefanini G et al (1999) Prurigo nodularis (Hyde's prurigo) disclosing celiac disease. Hepatogastroenterology 46:2281-2284.
  13. Suárez C et al (1989) Prurigo nodularis associated with malabsorption. Dermatologica 169:211-214 .
  14. Tanis R et al (2019) Dupilumab Treatment for Prurigo Nodularis and Pruritis. J Drugs Dermatol 18:940-942.
  15. Tsianakas A et al (2016) Prurigo nodularis management. Curr Probl Dermatol 50:94-101.
  16. Vaidya DC et al (2008) Prurigo nodularis: a benign dermatosis derived from a persistent pruritus. Acta Dermatovenerol Croat 16:38-44
  17. Wieser JK et al (2020) Resolution of Treatment-Refractory Prurigo Nodularis With Dupilumab: A Case Series. Cureus 12:e8737
  18. Williams KA et al.(2021) Pathophysiology, diagnosis, and pharmacological treatment of prurigo nodularis. Expert Rev Clin Pharmacol 14:67-77.

  19. Woo PN et al (2000) Nodular prurigo successfully treated with the pulsed dye laser. Br J Dermatol 143: 215-216

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

Authors

Last updated on: 19.07.2021