October 2010

59-year-old man with 10 years history of intensely itchy skin suspected and treated as lichen planus.

Biopsy shows dermal inflammation and thickened nerve fibers high in the dermis and epidermis.

Hvad er diagnosen, og hvordan skal det behandles?

Answer

Diagnose: Prurigo Nodularis

• Nodular prurigo may occur at any age, but particularly in adults aged 20-60 years. Both sexes are equally affected.
• The lesions are usually grouped and numerous up to 200 per individual.
• The individual lesions appear as 1-3 cm in diameter with krustae and flaking.
• Itching is often very intense and lead to scarring.

Cause unknown but atopic dermatitis is often part of history.
Internal diseases, including iron deficiency, chronic renal failure, gluten enteropathy, thyroid disease, HIV infection should be excluded.
Skin biopsy shows markedly increased nerve fibers and nerve endings in the skin.

Local treatments include:

• Moisturizer
• Oral antihistamines
• Ultra Potent steroid creams applied under occlusion (cover with a plastic dressing)
• Corticosteroid injections (triamcinolone acetonide 10 to 40 mg / ml) in thicker tumors
• Coal tar ointment as a steroid alternative
• Calcipotriolsalve (local vitamin D3) may be more effective than topical steroids in some cases
• Capsaicin cream
• Cryotherapy

Antibiotic ointment and oral antibiotics may be applied to each infected lesions

Systemic treatments include:

• Phototherapy (UVB and PUVA)
• Anti-depressants such as Amitriptyline or Doxepin
• Oral steroids
• Thalidomide (reserved for very severe cases)
• Cyclosporin
• Systemic retinoids as acitretin, which could reduce the tumor and reduce the severity of itching
• Naltrexone, opiate antagonist