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.
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