Clinical AdvisorRaised Itchy Nodules

Could the understanding of PN’s immune and neural dysregulation provide insights into the pathophysiology of other itchy skin disorders?

The complexity of diagnosing and treating prurigo nodularis (PN) requires comprehensive patient evaluation and understanding of the condition’s pathophysiology. The patient’s history, presence of related comorbidities, and physical examination can all guide the clinician towards an accurate diagnosis, providing a pathway to effective management strategies.

Key Points:

• Prurigo nodularis (PN) is a skin condition characterized by firm, itchy lesions often linked to repeated scratching of the skin.
• Prevalence of PN varies widely, with estimates from 36.7 to 148.3 per 100,000 people. It tends to present predominantly in the sixth and seventh decades of life and more commonly among females and individuals with skin of color, particularly Black patients.
• PN’s pathophysiology largely involves immune and neural dysregulation, with key players including eosinophils, T-cells, and various neuropeptides contributing to the intense pruritus.
• Diagnosis is based on patients describing severe pruritus lasting for 6 or more weeks, and the appearance of clustered hyperkeratotic symmetric nodules on extensor surfaces. Laboratory tests and additional screens are recommended to identify associated comorbidities.
• Differential diagnosis for PN includes hypertrophic lichen planus, pemphigoid nodularis, nodular scabies, among others.
• Treatment options range from topical corticosteroids and anesthetic agents to systemic immunosuppressants and, in resistant cases, FDA-approved dupilumab.

Additional Points:

• The disease is associated with a variety of health conditions, including mental health disorders, HIV, hematologic malignancies, diabetes, liver and thyroid disorders, and end-stage renal disease.
• Biopsy may aid in diagnosing atypical presentations, but it is not usually necessary.
• Hypertrophic lichen planus often gets misdiagnosed as PN due to similar clinical appearance and biopsy findings.

Conclusion:

• Clinically diagnosing PN is a multifaceted task that demands a comprehensive understanding of the patient’s history, examination findings, and the disease pathophysiology. This case demonstrates how an effective diagnostic approach and targeted treatment can help manage this challenging condition.

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Did You Know?
Data indicates a 3.4-fold increase in the odds of developing Prurigo nodularis (PN) in Black patients compared to White individuals, highlighting the role of racial disparities in the prevalence of this dermatological condition.