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Prurigo nodularis—A case report
Prurigo nodular – un caso clínico
Family Medicine Residents at ACES Vale Sousa Sul, Penafiel, Portugal
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"apellidos" => "Costa Martins" "email" => array:1 [ 0 => "joanaccostamartins@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Magno" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Family Medicine Residents at ACES Vale Sousa Sul, Penafiel, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Prurigo nodular – un caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 756 "Ancho" => 1007 "Tamanyo" => 94526 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical image of the patient's lesions.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 60-year-old retired man with a medical history of arterial hypertension, type 2 diabetes mellitus, grade II obesity (BMI 38<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>), dyslipidemia and severe obstructive sleep apnea syndrome. He presented to his primary care center with pruritic lesions on the lower quadrants of the abdomen and more prominently on the gluteal region and both thighs, with a two-week history of progression. On physical examination, nodular lesions measuring approximately 1<span class="elsevierStyleHsp" style=""></span>cm in diameter were observed. These lesions exhibited abrasions, erythema, and crusting (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), with some lesions showing yellowish exudate. After a diagnosis of prurigo nodularis, he was prescribed oral antihistamine (bilastine 20<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h for 2 weeks), topical corticosteroid (betamethasone cream once daily for 2 weeks), and topical antibiotic (mupirocin once daily for 7 days). A follow-up appointment was scheduled for 3 weeks, revealing significant improvement of the lesions, although complete resolution was not achieved.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Prurigo nodularis (PN) is a chronic inflammatory skin disorder characterized by the presence of multiple symmetrically distributed, intensely pruritic, and hyperkeratotic nodules that can significantly impact a patient's quality of life due to intense itching and sometimes challenging treatment.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">PN is a diagnosed clinically, necessitating a comprehensive history and physical examination for accurate diagnosis, and is relatively infrequent in primary care settings, underscoring the importance of recognizing the diagnosis and implementing appropriate treatment measures.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3</span></a> The hallmark of PN is severe itch that surpasses the intensity of other chronic pruritic skin conditions like atopic dermatitis and psoriasis. During physical examination, patients with PN typically present with elevated, firm, and nodular skin lesions ranging in size from a few millimeters to 2<span class="elsevierStyleHsp" style=""></span>cm.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,3</span></a> These lesions are frequently excoriated and covered with crust due to persistent itching and subsequent scratching by patients.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> This clinical presentation aids in diagnosing PN based on pruritic lesions.</p><p id="par0020" class="elsevierStylePara elsevierViewall">While the exact cause of this condition remains unknown, previous studies highlight the significant interaction and dysregulation between immune cells and neuronal circuitry as factors in the pathogenesis of PN.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> The pathogenesis of PN is also thought to be a cutaneous reaction pattern due to vicious cycles of chronic itch followed by repeated scratching.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Various comorbidities have been linked to PN, although it's uncertain whether these conditions directly contribute to PN or arise as a consequence of a shared systemic process responsible for the skin lesions of PN.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> For instance, PN has been notably linked with type 1 and type 2 diabetes mellitus.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Additionally, patients with PN tend to exhibit higher odds of hypertension, hyperlipidemia, and obesity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> In this case report, the patient exhibits type 2 diabetes, hypertension, and obesity, aligning with the common comorbidities associated with prurigo nodularis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Effective treatment can be difficult to achieve, and sometimes several attempts have to be made. In addition to this, most of the treatments are used off-label. The main goal of treatment is to reduce itching and the lesions. In most cases a multimodal approach and concomitant treatment is necessary.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Topical treatment is often considered first-line treatment, especially corticosteroid along with emollients. Other topical treatments include calcineurin inhibitors, vitamin D analogs and capsaicin, that can be used when the topical corticosteroid proved to be inadequate.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> UV phototherapy is a feasible treatment choice, in certain type of patients.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Systemic therapeutic choices include antihistamines, immunosuppressants, gabapentinoids, opioid modulators, neurokinin 1 receptor antagonists, antidepressants and biologic drugs, that can be used in refractory cases.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Benefits versus risk of all these drugs should be considered in the first place, before starting any treatment.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient's consent was obtained and the ethical and confidentiality standards have been respected in the preparation of this article.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 756 "Ancho" => 1007 "Tamanyo" => 94526 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical image of the patient's lesions.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Practical approaches for diagnosis and management of prurigo nodularis: United States expert panel consensus" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Elmariah" 1 => "B. Kim" 2 => "T. Berger" 3 => "S. Chisolm" 4 => "S.G. Kwatra" 5 => "N. Mollanazar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2020.07.025" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2021" "volumen" => "84" "paginaInicial" => "747" "paginaFinal" => "760" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32682025" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prurigo nodular, un reto terapéutico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Redondo-Sendino" 1 => "M.C. Gil-Muñoz" 2 => "J.I. 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Kwatra" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2020.04.183" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol" "fecha" => "2020" "volumen" => "83" "paginaInicial" => "1559" "paginaFinal" => "1565" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32454098" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "IFSI-guideline on Chronic Prurigo including Prurigo nodularis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Ständer" 1 => "M. Pereira" 2 => "T. Berger" 3 => "C. Zeidler" 4 => "M. Augustin" 5 => "S. 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