INDIVIDUAL ARTICLE: Management of Prurigo Nodularis
December 2023 | Volume 22 | Issue 12 | SF365502s15 | Copyright © December 2023
Published online November 28, 2023
Sarina B. Elmariah MD PhD MPHa*, Lindsay Tao BSa*, Rodrigo Valdes-Rodriguez MDc, Vivian Laquer MDb
aDepartment of Dermatology, University of California San Francisco, CA
bFirst OC Dermatology Research, Fountain Valley, CA
cDepartment of Dermatology, University of Texas San Antonio, TX
*Shared first co-authors
Abstract
Background: Prurigo nodularis (PN) is a chronic disease characterized by intense pruritus and nodular lesions associated with reduced quality of life. Until recently, no US Food and Drug Administration (FDA)-approved therapies have been available for the management of PN. Treatment regimens have been highly variable and clinical management guidelines are lacking overall; formal treatment guidelines do not exist within the US. In 2022, dupilumab became the first FDA-approved medication for PN. Multiple novel agents that target the neuroimmune underpinnings of the disease are currently in development and show promise for this challenging disorder.
Objective: To review current treatments and emerging therapies for effective management of patients with PN.
Methods: We reviewed publications on PN management identified from PubMed, Embase, Web of Science, and the Cochrane Library. We also included publicly available data on clinical trials for PN therapies reported on the US National Library of Medicine ClinicalTrials.gov, the International Conference on Harmonisation-Good Clinical Practice (ICH-GCP) Database, and the European Clinical Trials (EudraCT) Database.
Results: The recommended management of PN begins with an assessment of disease severity, including disease burden and pruritus intensity, and evaluation of comorbid medical disorders. Treatment goals include resolution of itch, improvement in nodules or cutaneous lesions, and improvement in quality of life. Therapies should be selected based on a patient’s clinical presentation and comorbidities. Treatment should simultaneously address the neural and immunologic components of PN. Combination therapy, particularly with conventional agents, may be beneficial.
Limitations: Data on most conventional PN treatments are limited to anecdotal reports, small clinical trials, or expert consensus recommendations. No head-to-head comparative trials have evaluated the relative efficacy of conventional and/or emerging agents, or combination therapy.
Conclusion: An effective treatment approach for patients with PN should reduce pruritus, allow nodular lesions to heal, and improve individual quality of life. The treatment landscape for PN is rapidly evolving with one FDA-approved agent and several new promising therapies on the horizon.
J Drugs Dermatol. 2023;22:12(Suppl 2):s15-22.
INTRODUCTION
Prurigo nodularis (PN) is a chronic skin disease classically characterized by refractory pruritus and nodular skin lesions, although a wide spectrum of variation in both sensory symptoms and lesional appearance may exist.1 Whereas PN was once considered a psychiatric disorder, accumulating data demonstrate that neural dysfunction and immune dysregulation are central to PN pathophysiology.2,3 Studies comparing burden of disease and health utility scores in patients with PN to those with other cutaneous and/or systemic disorders have consistently shown that PN patients not only suffer from higher disease burden and more severely reduced quality of life (QoL) compared to other skin diseases (including psoriasis, atopic dermatitis (AD), and cutaneous T cell lymphoma),4,5 but PN imposes a greater burden on individuals than hypertension, diabetes, stroke, bronchitis and chronic kidney disease requiring hemodialysis.6 Despite the overwhelming disease burden in this patient population, conventional treatments for PN have fallen short of providing meaningful symptomatic relief and durable disease control.
