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The Cutting Edge: Challenges in Medical and Surgical Therapies
July 2012

Treatment of Refractory Prurigo Nodularis With Lenalidomide

Arch Dermatol. 2012;148(7):794-796. doi:10.1001/archdermatol.2011.2918

Prurigo nodularis is an intensely pruritic disorder in which chronic scratching and rubbing lead to the formation of eroded and excoriated skin nodules that may become generalized. Therapy for prurigo nodularis is notoriously difficult, and relief of pruritus and clearing of the skin lesions is exceedingly difficult to achieve.

A 45-year-old African American woman was seen with a 10-year history of severe generalized prurigo nodularis refractory to numerous topical and systemic agents. Her medical history was significant for hypertension, migraines, insomnia, depression, and mild asthma. At presentation, greater than 30% of her body surface area was covered with more than 200 hyperpigmented, lichenified, crusted papules and nodules (diameter range, 0.5-2.0 cm) distributed over her abdomen, chest, back, bilateral upper and lower extremities, and palms and soles. Histologic examination of a representative lesion was consistent with the diagnosis of prurigo nodularis. Intense pruritus caused an inability to sleep through the night and difficulty concentrating on tasks, which led to a depressed mood and significant reduction in her quality of life. Her prurigo nodularis could not be ascribed to any dermatologic or systemic cause. Numerous therapies had been used, including several topical corticosteroids and oral and topical antihistamines, topical tacrolimus, cryotherapy, UV light therapy (UV-B and psoralen–UV-A), oral dapsone, buspirone, 3-week bursts of prednisone, and cyclosporine for 3 months, none of which provided relief. When the patient was treated with prednisone (60 mg/d) for longer than 6 weeks, her prurigo nodularis was well controlled, but it flared when the prednisone was decreased to 50 mg/d.