Dupilumab Treatment for Prurigo Nodularis and Pruritis

September 2019 | Volume 18 | Issue 9 | Case Reports | 940 | Copyright © September 2019

Ross Tanis MD MS,ª Katalin Ferenczi MD,B Michael Payette MD MBAB

aUniversity of South Carolina School of Medicine, Columbia, SC 

BUConn Health, Department of Dermatology, Farmington, CT 

Abstract

Prurigo nodularis (PN) is a disease in which chronic scratching and picking of the skin due to intense pruritis results in papulonodules, notably in areas that are accessible to the patient. The pathophysiology is hypothesized to be mediated by a Th2 helper cell response, similar to that seen in atopic dermatitis, therefore, treatment of PN with dupilumab would be expected to elicit a therapeutic response. We demonstrated that treatment of PN with dupilumab significantly decreased pruritis and the size and number of new lesions after 2 months of treatment.

J Drugs Dermatol. 2019;18(9):940-942. 

INTRODUCTION

Prurigo nodularis is an intensely pruritic disease in which dome-shaped papulonodules result from chronic scratching and picking of the skin.1 Lesions typically occur on the extensor surfaces, back, chest, face and other areas that are easily accessible.1 Treatment is often challenging and unsatisfying. The pathogenesis of PN remains unclear but its association with atopic dermatitis (AD) intuitively allows for overlap in the treatment options to consider. In this case report, we present a patient with recalcitrant PN who failed many therapies for PN. The patient’s primary complaint was severe pruritis. Initiation of dupilumab significantly decreased pruritis and the size and number of new lesions also improved

CASE SYNOPSIS

We present a 43-year-old type III Hispanic female who presented with intensely pruritic papules and nodules that were firm and tan-to-brown-violaceous in color (Figure 1 A-B). Several lesions had hyperkeratotic scale. Pathology demonstrated psoriasiform epidermal hyperplasia with hypergranulosis, overlying compact hyperkeratosis and sparse papillary dermal perivascular lymphocytic infiltrate (Figure 2 A-B). Initially, only a handful of lesions were present, but new lesions continuously appeared and lesions never resolved. Over a 3-year period, treatment attempts with topical clobetasol, flurandrenolide tape, intralesional triamcinolone, cryotherapy, narrowband ultraviolet B therapy, and ultimately methotrexate (max dose 15 mg/week) failed to provide any improvement in the quality of the lesions or severe pruritis.

The patient was lost to follow-up for nearly 6 months, after which she returned with innumerable lesions. At that time,