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Nodular prurigo

NODULAR PRURIGO

What are the aims of this leaflet?

This leaflet has been written to help you understand more about nodular prurigo. It tells you what it is, what causes it, what can be done about it and where you can find more information.

What is nodular prurigo?

‘Pruritus’ is the word doctors often use for itching. ‘Prurigo’ is a related word, which describes the changes that appear in the skin after it has been itched and scratched for a long time. In nodular prurigo these changes look like firm very itchy bumps (nodules) on the skin’s surface. These can improve or resolve when the person stops scratching the area, although for many people this can be very difficult without proper and sometimes prolonged medical treatment.

What causes nodular prurigo?

It is not known what causes nodular prurigo, or makes the skin react in this way. However, once the skin has become itchy, scratching and rubbing will cause the skin nerve endings to become thicker, more inflamed and cause more itching; this in turn will make the condition worse.

  • Nodular prurigo may start after an insect bite in some people, for example.
  • Individuals who have prolonged periods of stress are more likely to scratch. Stress can therefore make nodular prurigo worse.
  • Up to 80% of people with nodular prurigo are atopic i.e. may have asthma, eczema, hay fever or other allergic conditions. 
  • There are several other medical conditions that may be associated with nodular prurigo that may need to be further investigated (see BAD leaflet on pruritus).

Is nodular prurigo hereditary?

No, apart from the fact that atopy (allergic conditions) runs in families and is associated with prurigo.

What are the symptoms of nodular prurigo?

The itching can be very distressing physically and psychologically. In some cases the itch can be so severe that it causes problems with sleep, work, relationships and mood.

What does nodular prurigo look like?

The skin shows many hard bumps that are intensely uncomfortable and can appear anywhere on the body. They are usually darker than the skin around them. They have a rough, thick surface and may have a scab, crust or scratch marks on top. The lumps are usually less than 1cm in diameter and can feel firm, tender and itchy. Some areas of skin can breakdown to form an ulcer. 

The lateral aspect or the sides of the arms and legs are the most commonly affected areas. However, the back, buttocks, shoulders and chest can also be affected. The mid-upper back is usually spared. There may additionally be some dark coloured skin with scars in the affected areas from deep scratching. Nodular prurigo is most common between 20 and 60 years of age. It can present in any racial group and in any gender, although it is seen most commonly in older women.

How is nodular prurigo diagnosed?

Symptoms of itching, and the typical skin lesions described above, are usually enough to make the diagnosis of nodular prurigo. If there is any doubt then your doctor can carry out a skin biopsy (cutting out one of the bumps under a localanaesthetic and sending it to a pathologist to examine under a microscope; this can help to confirm the diagnosis. Blood tests may be taken to check for other conditions that can make the skin itchy e.g. iron-deficiency anaemia, kidney or liver disease, vitamin D deficiency.

Can nodular prurigo be cured?

No. Nodular prurigo can be difficult to clear, but it can usually be controlled and should gradually improve over time, although this can take months or years in some patients. Affected individuals are advised not to scratch or rub the nodules, but in practical terms this is very difficult, without proper treatment as explained below.

How can nodular prurigo be treated?

The treatments for nodular prurigo are aimed at stopping the skin itching:

  • A strong steroid cream or ointment will usually be suggested to reduce the inflammation in the skin. It should be applied once or twice a day as per your doctor’s instructions. Usually only very strong steroids will give relief. An alternative treatment would be Protopic 0.1% ointment. This does not contain steroid but can have anti-inflammatory effects to help decrease itching.
  • Covering the affected skin with paste bandages or cling-film on top of the steroid can increase the effect of the steroid on the skin. This is useful for when the condition is very itchy or flaring. It also helps to reduce scratching by creating a barrier.
  • It is very important to stop using soaps, or shower gels or other cosmetics to wash with as they can dry the skin. Instead an emollient (such as your usual moisturiser or barrier cream should be used as a soap substitute and rinsed away.
  • It is equally important to apply emollients regularly throughout the day (at least twice) as this helps maintain good skin health. This is especially important in patients with nodular prurigo as their skin may be drier. Therefore emollients may help ease itching, reduce scaling, soften cracked areas and help the penetration of other topical treatments like steroids.
  • CAUTION: Emollients, creams, lotions and ointments contain oils which can catch fire. When emollient products get in contact with dressings, clothing, bed linen or hair, there is a danger that a naked flame or cigarette smoking could cause these to catch fire. To reduce the fire risk, patients using skincare or haircare products are advised to be very careful near naked flames to reduce the risk of clothing, hair or bedding catching fire. In particular smoking cigarettes should be avoided and being near people who are smoking or using naked flames, especially in bed. Candles may also pose a risk fire. It is advisable to wash clothing daily which is in contact with emollients and bed linen regularly.
  • An antihistamine tablet or syrup can help to reduce the feeling of itch. Non-sedative antihistamines, such as fexofenadine or cetirizine are best. Sedative anti-histamines may produce adverse health problems if used long-term.
  • Ultraviolet light treatment (narrowband UVB), given 3 times a week in the hospital for a treatment course lastly approximately 2-3 months, can help to reduce the quantity of nodules, prevent new nodules appearing and reduce the sensation of itch.
  • Psychological support or medication to relieve stress, anxiety or depression may be offered as this can help with mood and some symptoms of itch.
  • If nodular prurigo is very severe and the above have not been helpful, immune-suppressing treatments such as tablet steroids (short-term only), ciclosporinmethotrexate or azathioprine can be prescribed to help reduce inflammation. It is important to note that these treatments may cause additional side effects and will need regular monitoring with blood tests and clinic appointments.

Self care (What can I do?)

The most important but hardest thing to do is to stop scratching.

  • Anything you can do to take your mind off the itching will help to reduce or stop the scratching.
  • You may find that laying a cool damp flannel on the skin can reduce the feeling of itch. A cooled emollient (moisturiser) which has been kept in the refrigerator, or has added menthol, may also help.
  • Keep your bedroom cool and do not sleep with heavy or heat retaining bedclothes. If you are hot and itchy during the day a fan can help to cool the skin down.
  • Cotton clothing worn in layers can be better than heavier materials such as wool or synthetic products which do not absorb sweat as easily leading to overheating and itching.

Where can I get more information?

Links to patient support groups:

Nodular Prurigo International
136 Bedford Street South
Liverpool, L7 7DB
Web: www.nodular-prurigo.org.uk
E-mail: info@nodular-prurigo.org.uk

Web links to detailed leaflets:

http://patient.info/doctor/prurigo-nodularis-pro

www.dermnetnz.org/dermatitis/prurigo-nodularis.html

For details of source materials used please contact the Clinical Standards Unit (clinicalstandards@bad.org.uk).

This leaflet aims to provide accurate information about the subject and is a consensus of the views held by representatives of the British Association of Dermatologists: individual patient circumstances may differ, which might alter both the advice and course of therapy given to you by your doctor.

This leaflet has been assessed for readability by the British Association of Dermatologists’ Patient Information Lay Review Panel

BRITISH ASSOCIATION OF DERMATOLOGISTS
PATIENT INFORMATION LEAFLET
PRODUCED AUGUST 2004
UPDATED MAY 2010, MAY 2013, MAY 2016, JANUARY 2020
REVIEW DATE JANUARY 2023

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