QDo you have a top choice therapy for Prurigo Nodularis?

A
Nicholas Brownstone, MD

Nicholas Brownstone, MD

Dermatology Resident
Temple University Hospital
Philadelphia, PA

Prurigo nodularis (PN) is traditionally a difficult disease to treat because there are no FDA approved therapies. Therefore, clinicians must resort to off label therapies with little data on safety and efficacy. PN can present in many different ways. Patients may present with a few isolated nodules or some can present with disease involving a large percentage of their body. Sometimes PN is accompanied by severe pruritus. Given these varied presentations, it is difficult to select one top choice therapy.

For patients with a few isolated lesions, I like to use topical medium-to-high potency corticosteroids under occlusive wrap. This is a cheap, accessible and relatively effective treatment modality and I counsel patients to apply and wrap at bedtime. If patients require for immediate relief for a few isolated lesions, an intralesional steroid injection (10 mg/mL of triamcinolone) is an option as well. There is even evidence to show that excimer laser is effective, which may be a another good option for isolated lesions.1

For patients who present with more extensive disease, phototherapy with Narrowband-Ultraviolet B (NB-UVB) is a good option. Phototherapy is also effective for concurrent pruritus and is safe for patients with major medical co-morbidities who would otherwise be relatively contraindicated to take systemic agents. Also, new research in the field of inflammatory skin diseases has introduced the concept of “Atopic Dermatitis Spectrum Disorder” which includes related conditions of atopic dermatitis which may respond to the similar therapies.2 Given that PN is part of this spectrum, dupilumab has been used as an effective option for generalized PN and pruritus.3,4,5

With our current therapeutic armamentarium, I have trouble forseeing a day when we can treat PN as effectively as we can treat psoriasis. This is due to fact that the newer biologics agents, such as the IL-23 inhibitors risankizumab or guselkumab, are nearly able to clear full body psoriasis. However, there is hope. Currently in phase 2 trails, nemolizumab (an IL-31 inhibitor) has shown promising data for PN and in a recent trial it achieved a significant reduction in pruritus scores, as well as improvements in sleep quality and a reduction in the mean number of PN lesions.6 I am looking forward to more clinical trial data and innovations for the treatment of PN, which will ultimately benefit our patients.

References:

  1. Nakashima C, Tanizaki H, Otsuka A, Miyachi Y, Kabashima K. Intractable prurigo nodularis successfully treated with combination therapy with a newly developed excimer laser and topical steroids. Dermatol Online J. 2014;20(6):13030/qt9xp4640d.
  2. Butler DC, Simpson E, Guttman-Yassky E, et al. The atopic dermatitis spectrum disorder. Recognizing the clinical heterogeneity in patients with atopic related skin conditions in order to improve therapeutic decision-making and outcomes: an expert panel consensus statement. J Dermatolog Treat. Published online August 16, 2021:1-3. doi:10.1080/09546634.2021.1966356
  3. Beck KM, Yang EJ, Sekhon S, Bhutani T, Liao W. Dupilumab Treatment for Generalized Prurigo Nodularis. JAMA Dermatol. 2019;155(1):118-120. doi:10.1001/jamadermatol.2018.3912
  4. Holm JG, Agner T, Sand C, Thomsen SF. Dupilumab for prurigo nodularis: Case series and review of the literature. Dermatol Ther. 2020;33(2):e13222. doi:10.1111/dth.13222
  5. Zhai LL, Savage KT, Qiu CC, Jin A, Valdes-Rodriguez R, Mollanazar NK. Chronic Pruritus Responding to Dupilumab-A Case Series. Medicines (Basel). 2019;6(3):E72. doi:10.3390/medicines6030072
  6. Ständer S, Yosipovitch G, Legat FJ, et al. Trial of Nemolizumab in Moderate-to-Severe Prurigo Nodularis. N Engl J Med. 2020;382(8):706-716. doi:10.1056/NEJMoa1908316