How Do You Treat Prurigo Nodularis?

Prurigo nodularis (PN) is a chronic inflammatory skin condition characterized by firm, itchy, and often painful bumps (nodules) on the skin. It typically begins with intense itchiness, which can be widespread or limited to a specific part of the body.

The urge to scratch and rub the itchy areas leads to more itchiness and inflammation, eventually causing hard nodules develop in the areas that have been scratched, usually on the arms, legs, and trunk, says Jeffrey Cohen, MD, assistant professor of dermatology at the Yale School of Medicine in New Haven, Connecticut.

While prurigo nodularis is rare, people with PN are more likely to have other, more common skin conditions that cause extreme itchiness, such as atopic dermatitis (eczema).

PN can greatly diminish a person’s quality of life. “The itching associated with prurigo nodularis can be absolutely debilitating,” says Dr. Cohen. “There are some patients who can’t sleep at night or engage in activities that they need or want to engage in because they’re so itchy.”

Treatment for prurigo nodularis focuses on three main areas, according to the American Academy of Dermatology (AAD): skincare and daily practices to reduce skin irritation and scratching; medications that can reduce itchiness directly; and topical (applied to the skin) or systemic (oral or injectable) therapies aimed at stopping the itch-scratch cycle and flattening the skin lesions.

Skincare can play a significant role in helping to manage prurigo nodularis, says Cohen. Strategies include:

• Mild soaps
• Short, not-too-hot showers or baths
• Moisturizer, applied throughout the day
• Over-the-counter, itch-relieving lotions and ointments
• Regular fingernail trimming or wearing gloves of mittens at night
• Fragrance-free laundry detergent

Use mild soaps for showering or bathing. Harsh soaps, especially liquid or scented cleansers, can irritate skin and intensify itch.

Keep showers or baths short, and don’t make them too hot. Try to keep your bath or shower to less than 10 or 15 minutes, and dry the skin well (with gentle patting, not rubbing) right away, says Cohen.

Cohen also recommends avoiding very hot showers or baths: “Sometimes people with these very itchy conditions like prurigo nodularis find temporary relief when they take a very hot shower. However, it turns out that when you do that, you can lose a lot of moisture from your skin, which can contribute to itching and irritation.”

Apply moisturizer several times a day. Using an emollient throughout the day can help soothe your skin and alleviate itch, according to the AAD. Applying a fragrance-free moisturizer right after toweling off from a bath or shower is a good practice, says Cohen.

Dab on over-the-counter itch-reducing lotions and ointments. In addition to regular moisturizers, itch-relieving topicals may help calm skin, says Cohen. Options include calamine lotion, capsaicin cream, pramoxine hydrochloride (an anesthetic), and products that contain camphor, menthol, or phenol, per the AAD.

Keep fingernails trimmed and wear gloves or mittens while sleeping to avoid unintentional scratching. Even covering itchy areas with bandages or dressings can help prevent scratching, according to Yale Medicine.

Use fragrance-free laundry detergent. “People with prurigo nodularis should avoid fragrances, and one place where this can be a problem is laundry detergent,” says Cohen.

The main treatment choices for prurigo nodularis are:

• Topical corticosteroids
• Nonsteroidal topical medications
• Antihistamines
• Steroid injections
• Phototherapy
• Systemic therapies such as injectable biologics
• Cryosurgery (procedures using extreme cold to destroy unwanted tissue)
• Antidepressants

Topical Corticosteroids A mainstay of prurigo nodularis treatment. “These can be very effective at reducing itch and can even actually help take away some of the nodules themselves,” Cohen says.

Medical tape coated with a corticosteroid can relieve itch, serve as a protective barrier to prevent scratching, and help flatten bumps, per the AAD.

But topical steroids aren’t a long-term treatment: They can only be used for about two weeks or so at a time because they can thin or discolor skin, says Cohen.

Nonsteroidal Topical Medications Topical calcineurin inhibitors (TCIs) can help with symptoms of prurigo nodularis, says Cohen. Other medications in this group include pimecrolimus (Elidel) and tacrolimus (Protopic). Dermatologists may also prescribe a vitamin D derivative, calciprotriene (Dovonex).

Antihistamines Nonsedating antihistamines for daytime and sedating antihistamines at bedtime may calm prurigo nodularis itchiness, per StatPearls.

Steroid Injections “People who have a few very bothersome spots that don’t respond well to topical therapy sometimes do respond to steroid injection right into the lesion,” says Cohen. “This can be done multiple times, generally once a month, and that can really help.”

Phototherapy Exposure to ultraviolet (UV) light can be a next step for people with prurigo nodularis when topical therapies aren’t doing enough to manage inflammation and itching.

“People with prurigo nodularis who do phototherapy get exposed to UV light in a very controlled setting in the office; it’s not like going to a tanning bed,” says Cohen. “It’s a medical grade UV light that is very specific, effective, and well tolerated.”

One challenge with phototherapy is that it requires repeat visits. Patients usually receive it two to three times a week for several weeks, according to the AAD.

Systemic Therapies If phototherapy and topicals aren’t doing an adequate job of relieving symptoms, doctors may turn to systemic therapies, per the AAD. Among the choices:

• Dupilumab Dupilumab (Dupixent) injection is the first and only prurigo nodularis treatment approved U.S. Food and Drug Administration (FDA). It is a biologic medication administered via subcutaneous (below the skin) injection: typically, a 300 milligram dose administered via pre-filled syringe or prefilled pen every two weeks after an initial “loading” dose. In clinical trials, such as one reported in the journal NatureMedicine, the drug resulted in significant improvements in itch and in reducing or clearing nodules. Cohen calls the medication “new and highly effective.”
• Nemolizumab Although the FDA has not yet approved this monoclonal antibody for prurigo nodularis, research published in the The New England Journal of Medicine has shown that the medication is effective but is associated with gastrointestinal side effects.
• Immunosuppressants Medications such as methotrexate or cyclosporine can blunt the immune system in order to reduce inflammation and help with itch, but they also may cause serious side effects.

Thalidomide and lenalidomide are immunomodulators (medications that affect the immune system) that are sometimes used to manage prurigo nodularis, per StatPearls.

Cryosurgery This treatment can be used if others don’t help with the itch and pain of prurigo nodularis, says the AAD. But it’s often not a first or second option in people with darker skin because it can cause noticeable light spots, scarring, or both.

Antidepressants Antidepressants may help relieve itch, according to the AAD.

As for natural or complementary therapies for prurigo nodularis, none have been proven to help, says Cohen. “Some people have tried remedies such as apple cider vinegar, but that’s not really something that’s been well researched,” he says.

Prurigo nodularis can have an enormous impact on people’s quality of life and life function. “Treating this condition not only helps clear the nodules and reduce the itch, but it can also help restore quality of life, which we all deserve,” says Cohen.

Prurigo nodularis is associated with an increased risk for depression or anxiety. It’s important for both physicians and people with the condition to be aware of these potential issues in order to identify and address any mood disorders, says Cohen.

Because of this emotional and mental toll, the AAD recommends that people with the condition seek out counseling or therapy.

Without treatment, the itch and bumps of prurigo nodularis can last months or even years, says the AAD. When the bumps go away, flat dark spots or spots that are lighter than the rest of the skin may remain where the nodules once were, called post-inflammatory pigment change.

There are a few important ways to minimize pigment changes from prurigo nodularis, says Cohen. These include:

• Early treatment
• Sun protection
• Bleaching cream

Early Treatment Treating prurigo nodularis early and managing it well are important steps for preventing permanent pigment change, says Cohen. “The fewer nodules that develop, the lower the potential for this,” he says.

Sun Protection Exposing skin spotting and scars to the sun not only makes the pigment changes more noticeable, but it can also make them persist longer. “It’s important to be careful and use sun protection, especially in those affected areas — this can help them fade over time,” says Cohen.

Bleaching Cream In some cases, if preventative measures don’t work and pigment changes don’t improve, a doctor may recommend bleaching cream such as hydroquinone. This would be on a case-by-case basis, and involve carefully weighing the risks and benefits, says Cohen.