Szepietowski JC, Weisshaar E (eds): Itch – Management in Clinical Practice.
Curr Probl Dermatol. Basel, Karger, 2016, vol 50, pp 94–101 (DOI: 10.1159/000446049)
Prurigo Nodularis Management
Athanasios Tsianakas  Claudia Zeidler  Sonja Ständer
Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster, Münster, Germany
Abstract
Characterized by the clinical presentation of individual to
multiple symmetrically distributed, hyperkeratotic, and
intensely itchy papules and nodules, prurigo nodularis
(PN) is a rare disease that emerges in patients with chron-
ic pruritus due to continuous scratching over a long pe-
riod of time. The itching and scratching of the lesions con-
tribute to the vicious cycle that makes this disease difficult
to treat, thus reducing the quality of life of affected pa-
tients. The pathogenesis of PN is ambiguous, although
immunoneuronal crosstalk is implicated. Its etiology was
found to be heterogenous. It can emerge as the symptom
of various dermatological, neurological, psychiatric, and
systemic diseases. There is currently no approved therapy
for PN. However, contemporary therapies consist of cal-
cineurin inhibitors, capsaicin, topical steroids, UV thera-
py, and a systemic application of antihistamines, anticon-
vulsants, μ-opioid receptor antagonists, and immuno-
suppressants. Multimodal therapy should be utilized in
order to achieve optimal results, including topical and
systemic symptomatic therapies.
© 2016 S. Karger AG, Basel
Prurigo nodularis (PN) is a disease identified by
the appearance of individual or multiple symmet-
rically distributed, hyperkeratotic, and erosive
papules and nodules on the surface of the skin.
There is currently no epidemiological data re-
garding the incidence and prevalence of PN. Af-
fected patients seldom present in the daily clinical
practice, thus making it difficult to document the
many contributing factors. All age groups are im-
pacted by PN, including the elderly (the most fre-
quently affected group) and children [1, 2]. Long-
term scratching in patients with chronic pruritus
is the reason for the development of PN. The re-
sulting lesions are intensely itchy, perpetuating
the vicious itch-scratch cycle that makes PN dif-
ficult to treat and reducing patient quality of life.
PN has various causes. 50% of patients with PN
also suffer from atopic predisposition or atopic
eczema [3]. Other diseases also contribute to the
emergence of PN, including inflammatory der-
matoses (e.g. bullous pemphigoid, lichen planus,
nummular eczema), internal diseases (e.g. diabe-
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tes mellitus, chronic kidney disease), infections
(e.g. HIV, hepatitis C), lymphoma (e.g. Hodg-
kin’s lymphoma), carcinomas, and neurological/
psychiatric diseases.
Therapy of Prurigo Nodularis
Establishing treatments for PN remains challeng-
ing and is made only more difficult by the small
amount of randomized clinical trials (RCTs)
available. In order to achieve optimal results, a
multimodal therapy consisting of topical and sys-
temic symptomatic therapies should be imple-
mented [4]. Various factors must also be taken
into consideration when creating an individual
treatment plan. These include age, comorbidities,
severity, impaired quality of life, and expected
side effects. Washing exclusively with mild soaps
and shower oils and maintaining a moisturizing
basis therapy are recommended basic care proce-
dures. A causal therapy strategy is very important
and implements treatment of a potentially under-
lying disease which can lead to the improvement
or sometimes even healing of PN (e.g. intensive
therapy of diabetes in diabetogenic PN) [5]. Phy-
sicians should aim for two goals concerning
symptomatic therapy: itch prevention and the
complete healing of PN lesions. These normally
require a combined therapy, considering the as-
pects mentioned above (for PN treatment op-
tions in clinical trials see table 1).
Topical Therapy of PN
Topical steroids, calcipotriol, and pimecrolimus
have previously been analyzed in RCTs with re-
gards to topical PN therapies. All remaining sub-
stances have been described in case series.
Topical Steroids
Topical steroids can produce an antipruritic ef-
fect and flatten nodules attributed to PN [6]. The
occlusive application of betamethasone 0.1%
cream on one side of the body and a moisturizing,
Prurigo Nodularis Management
Szepietowski JC, Weisshaar E (eds): Itch – Management in Clinical Practice.
Curr Probl Dermatol. Basel, Karger, 2016, vol 50, pp 94–101 (DOI: 10.1159/000446049)
antipruritic cream on the other was observed over
4 weeks in an RCT involving 12 patients with PN.
A significant reduction in pruritus was noted in
both treated areas, but its intensity was markedly
reduced on the half of the body treated with beta-
methasone [visual analogue scale (VAS) before:
8.8, VAS after: 3.9; in comparison to the moistur-
izing, antipruritic cream, VAS 5.6 afterwards].
Clinical improvement was also observed fol-
lowing the direct injection of triamcinolone ace-
tonide into the nodules [7]. This can be promis-
ing if the clinical picture of PN only shows few
lesions.
Topical Calcineurin Inhibitors
Topical calcineurin inhibitors, in contrast to top-
ical steroids, represent an intermittent, long-term
therapeutic opportunity. The antipruritic effect
of pimecrolimus on PN was recently determined
in an RCT consisting of 30 participants, during
which pimecrolimus was applied to one half of
the patient’s bodies, and hydrocortisone on the
other. Both halves of the body yielded positive re-
sults after 10 days (VAS before 7.1, VAS after
pimecrolimus 4.4, p < 0.001; VAS after hydrocor-
tisone 4.5, p < 0.001) [8]. This treatment was used
consistently for 8 weeks and resulted in a distinct
improvement, according to findings. In daily
practice, calcineurin inhibitors are used after fail-
ure of, or in case of contraindications for, topical
steroids.
Topical Calcipotriol
Topical calcipotriol has also been proven to be ef-
fective in treating PN. A 50-μg/g calcipotriol oint-
ment was applied to one half of the body and 0.1%
betamethasone ointment to the other in an RCT
consisting of 10 patients. Treatment with the cal-
cipotriol ointment proved more successful. Two
weeks of using this ointment resulted in less PN
lesions than 4 weeks of treatment with betameth-
asone valerate [9].
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Table 1. Treatment of PN based on literature reviews

Drug class Substance Dosage Appli- Patients, Study Ref.

cation n design

Corticosteroid Betamethasone Betamethasone vs. moisturizing itch Topical 12 RCT 6

relief cream
Triamcinolone 7.5 – 20 mg every 3 – 4 weeks Intralesional 1 CS
Triamcinolone Modified Goeckerman scheme (UVB + UV, topical 5 CR 18
cream 0.1% + LCD 2% + topical steroid)
clobetasol 0.05%
Calcineurin Pimecrolimus 1% pimecrolimus cream/day, other half Topical 30 RCT 8
inhibitors of the body 1% hydrocortisone cream/
day
Derivative of Calcipotriol 50 μg/g calcipotriol ointment/d, other Topical 10 RCT 9
vitamin D half of the body 0.1% betamethasone
valerate/day
Other topical Capsaicin Capsaicin (0.025–0.3%) 4 – 6 times/day Topical 33 CS 10
treatment
Antihistamines Ketotifen 1 mg/day for 4 weeks 27 40

Antihistamines + Montelukast + 10 mg montelukast/day and 240 mg p.o. 12 CS 14

leukotriene fexofenadine fexofenadine twice daily
receptor
antagonists
UV phototherapy UVB excimer + UVB 308-nm excimer light and bath UV 22 RCT 15
bath PUVA PUVA
UVA Mean total dose 6.07 J/cm2 UV 19 CS 17
Median number of 23 phototherapy
treatments (range 7 – 37)
UVB, topical Patient 1: 24 UVB treatments 3×/week UV 2 CR 47
PUVA (total dose 6,234 mJ/cm2), topical PUVA 2
months 3×/week (total dose 240 J/cm2)
Patient 2: 30 UVB treatments (total dose
7,239 mJ/cm2), topical PUVA (total dose
240 J/cm2)
UVA, bath PUVA Not applicable UV 15 CS 41
UVB 311 nm 1×/week cumulative dose 23.88 J/cm2, UV 10 CS 16
mean of 24.3 irradiations
UV phototherapy UVB + LCD + UVB + LCD 5 times weekly plus topical UV, topical 5 CS 18
+ topical steroids clobetasol clobetasol occlusive for 4 h
Excimer 308 nm 2 times/month for 7 months plus topical UV, topical 2 CR 42
steroid
Anticonvulsants Gabapentin 300 mg 3 times daily p.o. 4 CS 21
Pregabalin 75 mg/day p.o. 30 CS 22

μ-Opioid Naltrexone 25 – 150 mg/day p.o. 65 CS 26

receptor Naltrexone 50 – 100 mg daily p.o. 17 CS 43
antagonist Naltrexone 5 mg daily p.o. 13 CS 44
Naltrexone 50 – 150 mg daily p.o. 33 CS 45

Antidepressants Paroxetine vs. 20 mg paroxetine daily 50 mg p.o. 50 PCT 29

fluvoxamine fluvoxamine daily
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96 Tsianakas  Zeidler  Ständer

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Table 1 (continued)

Drug class Substance Dosage Appli- Patients, Study Ref.

cation n design

Immuno- Cyclosporine 3 – 5 mg per kg cyclosporine/day p.o. 14 CS 30

suppressants Lenalidomide 10 mg lenalidomide/day p.o. 1 CR 36
Lenalidomide 5 mg lenalidomide/day for 2 years p.o. 1 CR 35
Methotrexate 7.5 – 20 mg once weekly s.c. 13 CS 31
Thalidomide average 100 mg thalidomide/day p.o. 42 CS
Tacrolimus Oral 20 mg/day p.o. 1 46

Immunoglobulins Human 2 g per kg IVIG for 3 days, once monthly i.v. 1 CR 37

immunoglobulins
Neurokinin 1 Aprepitant 80 mg/day p.o. 13 CS 38
receptor
antagonists

CS = Case series; CR = case report; p.o. = per os; s.c. = subcutaneous; i.v. = intravenous; IVIG = intravenous immunoglobulins.

Topical Capsaicin Antihistamines

Multiple daily applications of topical capsaicin can
inhibit pruritus attributed to localized and neuro-
pathic forms of PN (e.g. brachioradial pruritus)
[10]. Capsaicin binds to the heat-activated ion
channel transient receptor potential cation chan-
nel V1 expressed in sensory nerve fibers and kera-
tinocytes [11]. Thirty-three patients with PN re-
ported reduced itching and an improved com-
plexion within 12 days, during which they ap-
plied various concentrations of capsaicin creams
(0.025–0.3%) 4–6 times daily. Creams and oint-
ments are recommended mainly for treating local-
ized PN because of the necessary multiple daily
applications. Therapy with ketamine, lidocaine,
and amitriptyline [12] can be an interesting alter-
native to other multimodal topical therapies as
they also target transient receptor potential chan-
nels.
Systemic Therapy for Prurigo Nodularis
Since a targeted therapy only is often not suffi-
cient to maintain control of PN, a combination
with systemic therapies becomes necessary.
Antihistamines are frequently implemented into
PN therapies due to an increased quantity of mast
cells found in PN lesions, although RCTs have not
yet carefully examined their effects on PN. A case
series noted the efficacy of a high-dose therapy
consisting of a nonsedative antihistamine, taken
4 times daily, and, if necessary, a combination
therapy of a sedative antihistamine taken at night
[13]. Antileukotriene agents and antihistamines
are often combined: 10 mg of montelukast and
240 mg of fexofenadine were, over 4 weeks, taken
twice daily by 12 patients with PN. Before thera-
py, the number of lesions ranged between 10 and
290 (mean 107.6). After 4 weeks of treatment,
there was not only considerable improvement
and signs of healing, but also a reduced number
of lesions (0–154, mean 42.7) [14].
UV Phototherapy
PN may be resistant to topical or intralesional ste-
roid applications. For such patients, UV photo-
therapy is a viable therapeutic alternative, espe-
cially for elderly patients prone to multimorbidity
and multimedication. Twenty-two patients with
PN were treated with PUVA therapy 4 times
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weekly for 5 weeks or a combination of bath
PUVA and UVB excimer laser therapy 2 times
weekly for 5 weeks. An accelerated healing pro-
cess was demonstrated in patients who were ad-
ditionally treated with a 308-nm excimer laser in
order to reduce PUVA doses by 30% [15]. UVB
therapy, consisting of 24 total sessions, was found
to reduce the lesions of 10 patients after only 6
sessions [16]. A 79% improvement in PN symp-
toms was reported by 19 patients who received
UVA therapy after an unsuccessful pretreatment
of steroids, antihistamines, and other antipruritic
treatments, although 4 patients reported no effect
[17].
A modified Goeckerman regimen was report-
ed to be effective for 4 patients [18]. After failure
of standard narrowband or broadband UVB ther-
apy, a daily multistep broadband UVB therapy
was administered daily, followed by the occlusion
of crude coal tar and topical steroids with a ban-
dage for 4 h. Improvements were noted in 3 pa-
tients after 5 treatments. It is important to re-
member that this regimen should be exercised
with caution in select patients due to controversy
about the potential carcinogenicity of tar [19].
Anticonvulsants
Anticonvulsants such as gabapentin and pregaba-
lin may be taken into consideration for patients
who are unresponsive to other forms of treatment.
RCTs testing their efficacy have proven an anti-
pruritic effect and therefore they are frequently
used in therapies for chronic pruritus [20]. Cur-
rently, only various case series employing gaba-
pentin and pregabalin have indicated a reduced
pruritus intensity in PN patients. According to
one case series, pruritus was reduced in 4 patients
who took 300–900 mg of gabapentin daily for 2
months [21]. Pruritus symptoms receded consid-
erably (up to 76%) in 30 patients who took 75 mg
of pregabalin once a day for 1 month. After 3
months of continuous treatment, the mean pru-
ritus intensity was, according to VAS (0–10),
strongly reduced from 8.2 ± 2.0 before therapy to
98
Szepietowski JC, Weisshaar E (eds): Itch – Management in Clinical Practice.
Curr Probl Dermatol. Basel, Karger, 2016, vol 50, pp 94–101 (DOI: 10.1159/000446049)
1.5 ± 1.1 after therapy. This proved to be statisti-
cally significant (p < 0.0001) [22]. The precise ac-
tion mechanism of these substances remains un-
clear, but stabilization of the spinal nerve mem-
brane is possibly caused by blockage of the calcium
channels, restricted synthesis of the neurotrans-
mitter glutamate, or reinforcement of the GABA
inhibitory mechanisms, so that incoming signals
are blocked at the presynaptic membrane [23].
Properly adjusting dosages for the elderly and
those with renal failure should be taken into con-
sideration, as well as the side effect profile.
Opioid Receptor Antagonists
Intravenous naloxone and oral naltrexone, both
μ-opioid receptor antagonists, have proven to be
effective therapies for PN [24]. Itchy intensity was
reportedly significantly decreased in an RCT in-
vestigating cholestatic PN [25]. In another trial,
65 patients with PN of varying origins received an
initial dose of 50 mg/day of naltrexone in a case
series which was later adjusted to 150 mg/day
[26]. Thirty-eight patients reported healing, and
67.7% alleged symptom reduction. Dizziness and
vomiting are among some of the reported side ef-
fects to be taken into consideration for the first
few days of treatment.
Combining κ-opioid receptor agonists and
μ-opioid receptor antagonists such as nalbuphine
or butorphanol can have positive effects on PN
[27]. Nalbuphine has antipruritic properties, and
a phase II study testing its effects on PN is cur-
rently ongoing (NCT02174419) [28].
Antidepressants
Severe PN may also be treated with antidepres-
sants such as paroxetine, amitriptyline, and mir-
tazapine. Fifty patients with PN were treated with
either paroxetine or fluvoxamine for at least 2
weeks in a 2-arm, proof-of-concept study. Upon
success, the treatment was continued for 4-week
intervals. Scratch lesions healed entirely In 14 pa-
tients and partially in 17. The pruritus intensity
was significantly decreased [29].
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Immunosuppressants
Immunosuppressants present a viable therapeu-
tical option for patients affected by severe PN, al-
though associated risks and side effects must first
be taken into account. A number of case series
have documented the positive results of immuno-
suppressive treatments for patients with PN: 10 of
14 patients had a very positive response and an
improvement in symptoms (80–100%) after oral
administration of 3–5 mg per kg of cyclosporine,
and 3 patients had a positive response (40–70%)
[30]. One patient reported a slight response. It is
important to monitor blood pressure and various
laboratory results, for example kidney values,
during such a therapy.
Data on 13 patients subcutaneously treated
weekly with 7.5–20 mg of methotrexate were
evaluated in a retrospective study [31]. Ten pa-
tients had reported lesion improvement (75%)
and 2 only slight improvements.
Thalidomide is a neurotoxic and teratogenic
drug that has been used to treat PN, for which
several case series are also available [32, 33]. Data
on the effects of thalidomide on 280 patients with
pruritus, most with PN, were recently published
in a review. The majority of patients described
improvement of PN and itch intensity. Besides
teratogenicity, there is a variety of side effects as-
sociated with thalidomide consumption, includ-
ing fatigue, confusion, and sensory neuropathy.
In the first year of treatment, the incidence rate of
peripheral neuropathy was approximately 20%
[34].
Another case report describes a drastic im-
provement during another treatment with tha-
lidomide [35]. However, due to the development
of drug-induced neuropathy, thalidomide was
switched successfully to lenalidomide 5 mg/day, a
second-generation thalidomide analogue. In an-
other case report, a patient was administered 10
mg of lenalidomide [33]. After 1 month, the in-
tensity of the pruritus was not only reduced, but
the quantity of PN lesions had also diminished.
Despite this, the patient had to discontinue treat-
Prurigo Nodularis Management
Szepietowski JC, Weisshaar E (eds): Itch – Management in Clinical Practice.
Curr Probl Dermatol. Basel, Karger, 2016, vol 50, pp 94–101 (DOI: 10.1159/000446049)
ment after 3 months due to suspicion of a drug-
induced myopathy and neuropathy. No peculiar-
ities could be detected in neurological examina-
tions, but the patient’s neurological condition
showed improvements after ceasing lenalidomide
[36]. During this time, the PN remained in remis-
sion.
In a case report, intravenous immunoglobu-
lins produced a positive treatment response in pa-
tients with PN resulting from atopic dermatitis
[37]. The 58-year-old patient had not improved
in spite of prior use of UV therapy, local steroids,
and cyclosporine, and was administered intrave-
nous immunoglobulins 3 days per month in com-
bination with methotrexate. After 3 cycles of this,
his PN improved significantly and methotrexate
was confirmed as monotherapy.
Future Therapies
The efficacy of neurokinin 1 receptor antagonists,
such as aprepitant and serlopitant (VPD-737), on
treating PN is currently being analyzed in RCTs.
Past case series have already demonstrated a pos-
itive antipruritic effect on PN: 13 patients with
PN of various origins were treated once daily with
80 mg of aprepitant for 3–13 days (mean 6.6
days). The mean VAS reduction was 48.5% (p =
0.001) and scratch lesions were noticeably im-
proved [38]. A randomized, double-blind, place-
bo-controlled study on aprepitant in PN has been
completed, but the results have not yet been pub-
lished (DRKS00005594). A trial on serlopitant for
PN is still ongoing (NCT02196324).
Another study currently running in the US
and Europe is focused on the efficacy of nalbu-
phine, a dual κ-agonist/μ-antagonist opioid re-
ceptor, for PN (NCT02174419). At present, there
is no data for patients with PN available, but nal-
buphine has been proven to reduce itch associat-
ed with uremic pruritus, as seen in 12 of 14 pa-
tients [39].
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Conclusion
PN is a disease representing a therapeutic chal-
lenge. Despite this, current RCTs conducted on
novel targets, including neurokinin 1 inhibitors
and opioid receptors, offer hope in providing tar-
geted treatment for this intensely itchy disease.
References
1 Iking A, Grundmann S, Chatzigeorgaki-
dis E, et al: Prurigo as a symptom of
atopic and non-atopic diseases: aetio-
logical survey in a consecutive cohort of
108 patients. J Eur Acad Dermatol Vene-
reol 2013;27:550–557.
2 Amer A, Fischer H: Prurigo nodularis in
a 9-year-old girl. Clin Pediatr 2009;48:
93–95.
3 Tanaka M, Aiba S, Matsumura N, et al:
Prurigo nodularis consists of two dis-
tinct forms: early-onset atopic and late-
onset non-atopic. Dermatology 1995;
190:269–276.
4 Weisshaar E, Szepietowski JC, Darsow
U, et al: European guideline on chronic
pruritus. Acta Derm Venereol 2012;92:
563–581.
5 Ko M, Chiu H, Jee S, et al: Postprandial
blood glucose is associated with general-
ized pruritus in patients with type 2 dia-
betes. Eur J Dermatol 2013;23:688–693.
6 Saraceno R, Chiricozzi A, Nisticò SP, et
al: An occlusive dressing containing
betamethasone valerate 0.1% for the
treatment of prurigo nodularis. J Der-
matolog Treat 2010;21:363–366.
7 Richards RN: Update on intralesional
steroid: focus on dermatoses. J Cutan
Med Surg 2010;14:19–23.
8 Siepmann D, Lotts T, Blome C, et al:
Evaluation of the antipruritic effects of
topical pimecrolimus in non-atopic pru-
rigo nodularis: results of a randomized,
hydrocortisone-controlled, double-blind
phase II trial. Dermatology 2013;227:
353–360.
9 Wong SS, Goh CL: Double-blind, right/
left comparison of calcipotriol ointment
and betamethasone ointment in the
treatment of prurigo nodularis. Arch
Dermatol 2000;136:807–808.
100
Acknowledgements
We thank Emily Burnett for the help in preparation of
the manuscript. This chapter was funded by the Ger-
man Federal Ministry of Education and Research
(BMBF; No. 01KG1305).
10 Ständer S, Luger T, Metze D: Treatment
of prurigo nodularis with topical capsa-
icin. J Am Acad Dermatol 2001;44:471–
478.
11 Ständer S, Moormann C, Schumacher
M, et al: Expression of vanilloid receptor
subtype 1 in cutaneous sensory nerve
fibers, mast cells, and epithelial cells of
appendage structures. Exp Dermatol
2004;13:129–139.
12 Griffin JR, Davis, Mark DP: Amitripty-
line/ketamine as therapy for neuropath-
ic pruritus and pain secondary to herpes
zoster. J Drugs Dermatol 2015;14:115–
118.
13 Schulz S, Metz M, Siepmann D, et al: An-
tipruritische Wirksamkeit einer hoch
dosierten Antihistaminikatherapie.
Ergebnisse einer retrospektiv analysierten
Fallserie. Hautarzt 2009;60:564–568.
14 Shintani T, Ohata C, Koga H, et al: Com-
bination therapy of fexofenadine and
montelukast is effective in prurigo nod-
ularis and pemphigoid nodularis. Der-
matol Ther 2014;27:135–139.
15 Hammes S, Hermann J, Roos S, et al:
UVB 308-nm excimer light and bath
PUVA: combination therapy is very ef-
fective in the treatment of prurigo nodu-
laris. J Eur Acad Dermatol Venereol
2011;25:799–803.
16 Tamagawa-Mineoka R, Katoh N, Ueda
E, et al: Narrow-band ultraviolet B pho-
totherapy in patients with recalcitrant
nodular prurigo. J Dermatol 2007;34:
691–695.
17 Bruni E, Caccialanza M, Piccinno R:
Phototherapy of generalized prurigo
nodularis. Clin Exp Dermatol 2010;35:
549–550.
18 Sorenson E, Levin E, Koo J, et al: Suc-
cessful use of a modified Goeckerman
regimen in the treatment of generalized
prurigo nodularis. J Am Acad Dermatol
2015;72:e40–e42.
Szepietowski JC, Weisshaar E (eds): Itch – Management in Clinical Practice.
Curr Probl Dermatol. Basel, Karger, 2016, vol 50, pp 94–101 (DOI: 10.1159/000446049)
19 Paghdal KV, Schwartz RA: Topical tar:
back to the future. J Am Acad Dermatol
2009;61:294–302.
20 Gunal AI, Ozalp G, Yoldas TK, et al: Ga-
bapentin therapy for pruritus in haemo-
dialysis patients: a randomized, placebo-
controlled, double-blind trial. Nephrol
Dial Transplant 2004;19:3137–3139.
21 Gencoglan G, Inanir I, Gunduz K: Ther-
apeutic hotline: treatment of prurigo
nodularis and lichen simplex chronicus
with gabapentin. Dermatol Ther 2010;
23:194–198.
22 Mazza M, Guerriero G, Marano G, et al:
Treatment of prurigo nodularis with
pregabalin. J Clin Pharm Ther 2013;38:
16–18.
23 Scheinfeld N: The role of gabapentin in
treating diseases with cutaneous mani-
festations and pain. Int J Dermatol 2003;
42:491–495.
24 Phan NQ, Lotts T, Antal A, et al: Sys-
temic kappa opioid receptor agonists in
the treatment of chronic pruritus: a lit-
erature review. Acta Derm Venereol
2012;92:555–560.
25 Bergasa NV: The pruritus of cholestasis:
facts. Hepatology 2015;61:2114.
26 Brune A, Metze D, Luger TA, et al: Anti-
pruritische Therapie mit dem oralen
Opiatrezeptorantagonisten Naltrexon.
Offene, nicht placebokontrollierte An-
wendung bei 133 Patienten. Hautarzt
2004;55:1130–1136.
27 Dawn AG, Yosipovitch G: Butorphanol
for treatment of intractable pruritus. J
Am Acad Dermatol 2006;54:527–531.
28 Hawi A, Alcorn H, Berg J, et al: Pharma-
cokinetics of nalbuphine hydrochloride
extended release tablets in hemodialysis
patients with exploratory effect on pru-
ritus. BMC Nephrol 2015;16:47.
132.239.1.231 - 9/26/2016 1:53:23 AM
Univ. of California San Diego
Tsianakas  Zeidler  Ständer
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29 Ständer S, Böckenholt B, Schürmeyer-
Horst F, et al: Treatment of chronic pru-
ritus with the selective serotonin re-up-
take inhibitors paroxetine and
fluvoxamine: results of an open-labelled,
two-arm proof-of-concept study. Acta
Derm Venereol 2009;89:45–51.
30 Siepmann D, Luger TA, Ständer S: Anti-
pruritic effect of cyclosporine micro-
emulsion in prurigo nodularis: results of
a case series. J Dtsch Dermatol Ges 2008;
6:941–946.
31 Spring P, Gschwind I, Gilliet M: Prurigo
nodularis: retrospective study of 113
cases managed with methotrexate. Clin
Exp Dermatol 2014;39:468–473.
32 Andersen TP, Fogh K: Thalidomide in
42 patients with prurigo nodularis
Hyde. Dermatology 2011;223:107–112.
33 Taefehnorooz H, Truchetet F, Barbaud
A, et al: Efficacy of thalidomide in the
treatment of prurigo nodularis. Acta
Derm Venereol 2011;91:344–345.
34 Sharma D, Kwatra SG: Thalidomide for
the treatment of chronic refractory pru-
ritus. J Am Acad Dermatol 2016;74:
363–369.
35 Kanavy H, Bahner J, Korman NJ: Treat-
ment of refractory prurigo nodularis
with lenalidomide. Arch Dermatol 2012;
148:794–796.
Prof. Dr. Dr. Sonja Ständer
Department of Dermatology and Center for Chronic Pruritus, University Hospital Münster
Von-Esmarch-Strasse 58
DE–48149 Münster (Germany)
E-Mail sonja.staender @ uni-muenster.de
Prurigo Nodularis Management
Szepietowski JC, Weisshaar E (eds): Itch – Management in Clinical Practice.
Curr Probl Dermatol. Basel, Karger, 2016, vol 50, pp 94–101 (DOI: 10.1159/000446049)
36 Liu H, Gaspari A, Schleichert R: Use of
lenalidomide in treating refractory pru-
rigo nodularis. J Drugs Dermatol 2013;
12:360–361.
37 Feldmeyer L, Werner S, Kamarashev J,
et al: Atopic prurigo nodularis responds
to intravenous immunoglobulins. Br J
Dermatol 2012;166:461–462.
38 Ständer S, Siepmann D, Herrgott I, et al:
Targeting the neurokinin receptor 1
with aprepitant: a novel antipruritic
strategy. PloS One 2010;5:e10968.
39 Hawi A, Alcorn H Jr, Berg J, Hines C,
Hait H, Sciascia T: Pharmacokinetics of
nalbuphine hydrochloride extended
release tablets in hemodialysis patients
with exploratory effect on pruritus.
BMC Nephrol 2015;16:47.
40 Sharma AD: Oral ketotifen and topical
antibiotic therapy in the management of
pruritus in prurigo nodularis: a random-
ized, controlled, single-blind, parallel
study. Indian J Dermatol 2013;58:355–
359.
41 Väätäinen N, Hannuksela M, Karvonen
J: Local photochemotherapy in nodular
prurigo. Acta Derm Venereol 1979;59:
436–437.
42 Nakashima C, Tanizaki H, Otsuka A,
Miyachi Y, Kabashima K: Intractable
prurigo nodularis successfully treated
with combination therapy with a newly
developed excimer laser and topical ste-
roids. Dermatol Online J 2014;20:pii:
13030/qt9xp4640d.
43 Metze D, Reimann S, Beissert S, Luger
T: Efficacy and safety of naltrexone, an
oral opiate receptor antagonist, in the
treatment of pruritus in internal and
dermatological diseases. J Am Acad Der-
matol 1999;41:533–539.
44 Metze D, Reimann S, Luger TA: Effec-
tive treatment of pruritus with naltrex-
one, an orally active opiate antagonist.
Ann NY Acad Sci 1999;885:430–432.
45 Brune A, Metze D, Luger TA, Ständer S:
Antipruritic therapy with the oral opiod
receptor antagonist naltrexone. Open,
non-placebo controlled administration
in 133 patients (in German). Hautarzt
2004;55:1130–1136.
46 Halvorsen JA, Aasebø W: Oral tacroli-
mus treatment of pruritus in prurigo
nodularis. Acta Derm Venereol 2015;95:
866–867.
47 Hann SK, Cho MY, Park YK: UV treat-
ment of generalized prurigo nodularis.
Int J Dermatol 1990;29:436–437.
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