How Is Prurigo Nodularis Treated? | MyPrurigoTeam

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How Is Prurigo Nodularis Treated?

Medically reviewed by Kevin Berman, M.D., Ph.D.
Written by Maureen McNulty
Posted on September 21, 2022

Although there’s no cure for prurigo nodularis (PN) — also called nodular prurigo— there are several types of treatments for the condition. Doctors may recommend medications or other therapies to reduce itching or calm the immune system. PN treatment also frequently involves lifestyle changes or self-care strategies to keep your skin healthy and reduce itching.

The most important goal of treatment is usually to minimize itching. Stopping itch can help break the itch-scratch cycle in which itchy skin and subsequent scratching cause even itchier nodules (hard lumps) to form. If itching is blocked, the nodules may gradually go away.

Treating prurigo nodularis can be difficult. Being a less common condition, PN hasn’t been well-studied. Additionally, the U.S. Food and Drug Administration (FDA) hasn’t officially approved any treatments for prurigo nodularis. However, doctors sometimes recommend treatments for off-label use that can help lessen PN symptoms. Therapies that help manage other inflammatory skin disorders sometimes also work for PN.

The treatment plan that will work best for you will depend on how severe your PN is, how old you are, whether you have additional health problems, and how you feel about the side effects of different treatment options. It’s common to try multiple types of therapies before you find a regimen that works for you.

Initial Treatments for PN

PN treatment may begin with topical medications — creams or ointments you rub into your skin. There are a few over-the-counter options that may help calm itching. Look for lotions or creams that contain ingredients like menthol, phenol, camphor, pramoxine, or capsaicin. Calamine lotion may also relieve itching.

Over-the-counter creams may not be effective enough to treat the severe itching that often comes with PN. In this case, your dermatologist may prescribe stronger topical drugs. These include:

  • Calcineurin inhibitors such as tacrolimus (Protopic) or pimecrolimus (Elidel), which lower levels of immune system activity
  • Different forms of vitamin D such as calcitriol (Rocaltrol) or calcipotriol (Dovonex), which can make skin cells grow more normally and prevent your immune system from attacking the skin

Topical corticosteroids are another common initial treatment option for prurigo nodularis. These medications help prevent your immune system from causing inflammation or other abnormal reactions. In some cases, you can cover your skin with medical tape or bandages that contain topical steroids. Stronger topical steroids are necessary to reduce the itching from PN.

Many people notice that their PN gets worse in the evening or at night. This can sometimes make it difficult to get good quality sleep. If this is the case for you, it may help to take a sedating antihistamine — an anti-allergy drug that makes you feel very sleepy. Options include hydroxyzine (Atarax) or diphenhydramine (Benadryl). This type of drug has two benefits — it fights immune cells that may be causing abnormal reactions in your skin and helps you get a better night’s rest.

When Initial Treatments Are Ineffective

Initial PN treatments don’t work well for some people. If you try these treatments and find that they aren’t controlling your PN symptoms, your doctor may suggest other options.

In some cases, PN leads to very thick skin, making it difficult for topical medications to absorb into deeper skin layers. These skin lesions (abnormal skin areas) can be treated with injections of triamcinolone acetonide (Kenalog-40), a type of corticosteroid. Injecting the steroid directly into the nodules ensures it’s delivered to the area in which the inflammation is occuring.

Prurigo nodularis is also sometimes treated with cryosurgery. During this treatment, your doctor will use extremely cold liquid nitrogen to reduce inflammation or kill an area of skin tissue. Cryosurgery can help lessen itching and minimize nodules for people with PN. However, it can cause scarring or light patches of skin for people with darker skin, so this treatment may not be right for some. This treatment also can be painful.

Phototherapy or light therapy is another common treatment option for other types of skin diseases that cause inflammation. During these treatments, you are exposed to ultraviolet (UVA or UVB) light using a special device in your doctor’s office. You may also combine these treatments with a medication that makes your skin more sensitive to UV light. This is known as photochemotherapy, or PUVA. Another form of phototherapy involves removing nodules with a laser.

Oral Medications for Severe PN

If your PN is severe or hard to treat, your doctor may prescribe oral drugs (medications taken by mouth). These drugs travel all around the body through the bloodstream and can help treat PN in any location.

Immunosuppressants

Immunosuppressants and immunomodulators are drugs that block immune system reactions such as inflammation that are linked to PN. These medications include:

  • Cyclosporine (Gengraf)
  • Methotrexate (Trexall)
  • Cyclophosphamide (Cytoxan)
  • Azathioprine (Imuran)
  • Tacrolimus (Astagraf XL)
  • Dupilumab (Dupixent)
  • Oral steroids

Immunomodulatory Drugs

Medications like thalidomide (Thalomid) and lenalidomide (Revlimid) are immunomodulatory — they can help block certain immune system processes. They may also help people with PN by blocking nervous system signaling between the brain and skin.

Drugs That Block the Nerves

Other therapy options include gabapentin (Neurontin) or pregabalin (Lyrica). These medications can prevent nerve cells from becoming activated. This may help stop itch and pain signals from being sent from the skin to the brain.

Other Oral Medications

Early research has found that certain other types of drugs may help some people with PN, although additional studies are needed to learn more. Other drugs that may help block immune system or nervous system processes and treating itching include:

  • Opioid receptor antagonists such as naloxone (Narcan) and naltrexone (ReVia)
  • Monoclonal antibodies (laboratory-made proteins) that block part of the immune system, like Nemolizumab (Mitchga)
  • NK1r antagonists like aprepitant (Emend)

Self-Care Tips for People With PN

Lifestyle changes may help control itching regardless of other PN medications and treatments you are taking.

Prevent Scratching

The more you scratch, the more new nodules may form. Avoiding touching your skin can help you heal and may relieve symptoms in the long run.

Cover up the affected areas of skin as much as possible. Wearing long pants and long-sleeved shirts may help you avoid directly scratching your skin and could help minimize skin damage. Wearing a bandage over itchy skin areas may also help.

You may also want to cover your fingernails so that any itching is gentler for your skin. Try wearing gloves or keeping your nails cut very short.

Avoid Triggers

Factors that can trigger your PN and make itching worse include:

  • Heat or humidity
  • Sweating
  • High stress levels
  • Dry air
  • Clothes made from certain materials, such as polyester or wool
  • Certain skin care products that contain irritating ingredients

Keeping yourself cool and staying away from products that worsen your skin condition may help boost your quality of life while living with PN.

Practice Good Skin Care

Take care of your skin using a gentle cleansing routine. Use warm water (not hot) when bathing, and use your fingers to apply any skin products — loofahs, washcloths, or other tools may cause more irritation or inflammation. You may also want to avoid soap altogether or try using a mild soap. Shorter baths and showers may also help reduce itching.

Dry skin can lead to extra itchiness. It may help to regularly apply lotion or emollients to moisturize your skin.

Make sure that any skin products you use — lotions, body washes, facial cleansers, and other products — are designed to be used on sensitive skin. Fragrance-free and dye-free products may also help prevent additional skin irritation.

Treating Other Health Problems

PN is often linked to other conditions such as eczema, infections, or cancer that cause itching or make the prurigo nodularis worse. Treating these conditions is very important — if you manage the underlying cause, your PN symptoms may improve.

If your PN causes other problems, you may also need additional treatment. Many people with PN have skin infections and require treatment with antibiotics. Additionally, antidepressants or therapy may help those with PN who are experiencing anxiety or depression. Mental health treatments may also reduce stress, which can worsen PN.

Find Your Team

On MyPrurigoTeam, the social network for people with prurigo nodularis and their loved ones, members come together to ask questions, give advice, and share their stories with others who understand life with prurigo nodularis.

Are you living with prurigo nodularis? Share your experience in the comments below, or start a conversation by posting on your Activities page.

Posted on September 21, 2022
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Kevin Berman, M.D., Ph.D. is a dermatologist at the Atlanta Center for Dermatologic Disease, Atlanta, GA. Review provided by VeriMed Healthcare Network. Learn more about him here.
Maureen McNulty studied molecular genetics and English at Ohio State University. Learn more about her here.

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