Intractable prurigo nodularis

presented by Henry Foong, Ipoh, Malaysia
Abstract:  55 yo man with over a decade of pruritic nodules.

The patient is a 55 yr old man who presented with 2 months history of severely pruritic nodules on the upper/lower extremities and trunk. His problem started about 13 yrs ago when he had pruritic nodules on the scalp, hands and feet. He had seen a few dermatologists in town and was not getting better.  In 2003, I did a skin biopsy on one of the nodules and features were compatible with prurigo nodularis. There was no granuloma or vasculitis noted. He defaulted in 2009 seeking other traditional treatments and topical ointments.O/E:  The nodules and plaques were mainly over the dorsum of both hands and feet, knees, back of trunk and buttocks. The nodules were erythematous, excoriated and discrete. One important feature noted in this patient is that the lesions affected the back of trunk without any sparing of lesions over the central upper back where the hands would have difficulty in reaching it. There were no scalp lesions.

Clinical Photos:

Lab: Blood counts and biochemistry was unremarkable. IgE level is 230 KU/l (normal <88 IU) He runs a petrol station and did not seem to have much underlying stressors except the lesions over the hands and thighs were excruciatingly itchy.  He had a past history of IHD, hypertension, hypercholesterolemia with coronary artery bypass surgery done in 2006.

Therapy: I have treated him with multiple intralesional triamcinolone injection, topical coal tar ointment and oral MTX 17.5 mg weekly. I omitted dermovate ointment as I think he probably has overused topical steroids.

I am thinking of other options : PUVA, oral cyclosporin or biologics such as adalimumab.

Of the three, I probably choose cyclosporin and monitor his renal function closely.

I am not sure if I can get thalidomide but I think the drug is difficult to source in Malaysia.