Review
Diagnostic and treatment algorithm for chronic nodular prurigo

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Chronic nodular prurigo (CNPG) is a subtype of chronic prurigo, also called prurigo nodularis, and a chronic skin condition characterized by intensely pruritic nodular lesions. Although the exact cause of CNPG is unknown, it appears to result from a repetitive itch-scratch cycle induced by neuronal sensitization to chronic pruritus. CNPG is associated with an underlying dermatologic condition in about half of patients, and it can also be attributed to systemic, neurologic, psychogenic, or unknown causes. For most patients, multiple underlying causes are identified. Patients with CNPG often experience impaired quality of life, sleep disturbance, anxiety, and depression. To encourage consistent and accurate diagnosis and treatment of CNPG across regions, we are proposing a diagnostic and treatment algorithm that includes initial assessment of core symptoms, detailed dermatologic history and clinical examination, patient-reported outcomes, diagnostic workup, and recommended therapies. This information is supplemented with photographs to illustrate clinical appearance and disease severity. Because CNPG is often multifactorial and it can take months to years for lesions to heal, interdisciplinary cooperation and long-term management are important.

Section snippets

Diagnosis and treatment of chronic nodular prurigo

The initial assessment of a patient who presents with possible CNPG should include a medical history and cutaneous examination to determine if the core symptoms are present. These include the presence of pruritus for at least 6 weeks preceding the occurrence of multiple pruriginous lesions and history and/or signs of repeated scratching (eg, excoriations and scars).1 CNPG initially manifests with 1 or several grouped lesions and can progress to be generalized with numerous (up to hundreds) of

Treatment

Management of CNPG is challenging. Data from randomized controlled trials are limited, and there are currently no approved therapies specifically for CNPG.3 CNPG is usually treated with topical antipruritic therapies, such as emollients, corticosteroids, anesthetic agents, and calcineurin inhibitors; intralesional corticosteroids; or systemic antipruritic therapies, such as ultraviolet phototherapy (ultraviolet A/B), gabapentinoids, antidepressants, opioid antagonists, and immunosuppressants.3,

Future directions

Response to available therapies is often inadequate or associated with unpleasant adverse effects. Investigational therapies are currently being evaluated for the treatment of pruritus associated with CNPG and other underlying dermatologic conditions. Recent studies have shown the potential of neurokinin 1 receptor (NK1R) antagonists, μ-opioid receptor antagonists, interleukin (IL) 31 receptor antagonists, and IL-4 receptor antagonists to treat patients with CNPG. Initial evidence for the

Summary

CNPG is an intensely pruritic disease that is associated with impaired quality of life and adverse effects on sleep, social settings, relationships, work, and the patient's emotional well-being. Accurate and early diagnosis is important for optimal management of the disease and to potentially prevent scarring. Long-term management is important, because it can take months to years to achieve the ultimate goal of treatment, healing of pruriginous lesions. Interdisciplinary cooperation is

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    Funding sources: Supported by Menlo Therapeutics Inc.

    Disclosure: Dr HF Ständer is a member of scientific advisory boards and is a consultant for Menlo Therapeutics, Leo, Novartis, and Sanofi-Aventis. Dr Elmariah serves as a scientific advisor to Menlo Therapeutics, AOBiome, and Trevi Therapeutics. Dr Spellman was employed by Menlo Therapeutics Inc. Dr. S Ständer is a principal investigator for Dermasence, Galderma, Kiniksa, Menlo Therapeutics, Trevi Therapeutics, Novartis, and Vanda and is a member of scientific advisory boards and a consultant for Almirall, Astellas, Beiersdorf, Celgene, Galderma, Kiniksa, Kneipp, Maruho, Menlo Therapeutics, NeRRe Therapeutics, Novartis, Sanofi, Sienna, and Trevi Therapeutics. Dr Zeidler has no conflict of interest to declare.

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