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Therapeutic Approach

Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intensely pruritic and firm nodules on the extensor surfaces of the extremities and trunk. PN can present in association with underlying systemic disorders (eg, chronic kidney disease, liver disease, HIV, type II diabetes) but can also present independently. Subsets of PN patients have concomitant atopic dermatitis (AD) and may be managed with approved therapies for AD. Although there are currently no FDA-approved therapies for PN, off-label medications have been used to varying efficacy, and there are several emerging agents at varying levels of development. As PN is related to underlying neuroimmune dysregulation, the authors have found that patients with increased blood eosinophils and/or IgE levels on peripheral blood testing are highly predictive of having Th2 immune polarization and a subsequent improved response to immunomodulatory therapy. In the authors’ experience, milder disease with limited skin involvement is usually treated with topical steroids, NBUVB, and gabapentin, whereas generalized disease is treated with immunomodulator therapies such as methotrexate, cyclosporine, or dupilumab. As PN patients have systemic inflammation, most patients will require therapy with systemic agents in addition to topical therapies. See Table 3-1.

Table 3-1Prurigo Nodularis Treatment Table

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