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Chapter 91: Actinic Prurigo

Bonnie W. Leung; Travis Vandergriff

ACTINIC PRURIGO

Therapeutic Approach

Actinic prurigo is a rare chronic sunlight-induced pruritic and excoriated papular or nodular eruption with postinflammatory scarring that disproportionately affects indigenous peoples of North and South America. It typically begins in childhood, usually by age 10 and may remit at puberty. Strong association with HLA-DR4 has been identified. Controlled clinical trials are limited. While photoprotection is first-line, actinic prurigo is unique among photodermatoses in its reponse to thalidomide. See Table 91-1.

Table 91-1Actinic Prurigo Treatment Table
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Table 91-1 Actinic Prurigo Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Broad-spectrum sunscreen (mineral sunscreen for UVA and UVB coverage, SPF >30) and sun avoidance First-line Sun protection Regular application daily None None III1-3
High-potency topical corticosteroids Acute episodes Anti-inflammatory Intermittent short course, up to 14 d Atrophy, pigment change, telangiectasias, striae formation, acneiform eruption None III1-6
Calcineurin inhibitor Acute episodes Anti-inflammatory Up to twice a day Skin irritation None III5
Systemic Therapy
Oral antihistamine (eg, hydroxyzine, cetirizine) Acute episodes Reduce pruritus Hydroxyzine (12.5-25 mg po TID prn itch in adults); cetirizine 10 mg daily Dizziness, sedation, anticholinergic symptoms, GI upset None III3,5,6
Oral corticosteroids Episoidic exacerbations Anti-inflammatory Start with 0.5 mg/kg prednisone daily, then taper down Immunosuppression, hyperglycemia, HPA axis suppression, osteoporosis Blood pressure, glucose, triglyceride, electrolytes every 1-2 mo (may decrease frequency over time) III6
Thalidomide Severe, persistent disease Anti-inflammatory Usually start at 100 mg daily for adults and decrease to 50 mg daily for maintenance, treatment duration 1-3 mo; lower doses for children Teratogenicity, drowsiness, headache, constipation, weight gain, peripheral neuropathy, increased risk of thromboembolism, leukopenia, thrombocytopenia Liver and thyroid function (monthly), complete blood count (monthly), pregnancy testing (weekly during the first month, then monthly) III5-8
Cyclosporine Refractory disease Suppression of T-cell proliferation and activity 2.5 mg/kg/d Nephrotoxicity, hepatotoxicity, hirsutism, hypertension Renal and liver function, fasting lipid, blood pressure, electrolytes including magnesium and uric acid (every 2 wk for the first 2 mo, then monthly) III9
Procedural Therapy
Narrowband UVB Refractory disease Decrease cell proliferation, immunosuppression, desensitization 3x/wk, starting in early spring; doses depend on skin type; start with 50% MED and increase 10%-15% per session as tolerated; treatment duration approximately 5 wk Erythema, pruritus, provocation of the eruption None III6,10-12
Psoralen and UVA Refractory disease Increase in pigmentation and epidermal thickness; suppression of immune response 2x/wk Erythema, photoaging, increased risk of skin cancer, nausea Annual skin examination III6,13

Levels of evidence are based on the Journal of the American Academy of Dermatology guidelines: level IA evidence includes evidence from meta-analysis of randomized controlled trials; level IB evidence includes evidence from ≥1 randomized controlled trial; level IIA evidence includes evidence from ≥1 controlled study without randomization; level IIB ...

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