Prurigo

[L. the itch]

Papules induced by scratching

The term Besnier's prurigo is applied to
the chronic papular or lichenified form of
atopic eczema

Nodular Prurigo
(Prurigo Nodularis)

Etiology
The cause is unknown
Emotional stress seems to be a
contributory factor in some cases
In 20% the condition starts after an insect
bite
There is increase in number of
neutrophils, mast cells, Merkel cells and
IL-31

Clinically
Patients are mostly middle-aged to elderly
They complain of a long-standing history of
severe, unremitting pruritus and they can
point out specific sites where they began
feeling itchy
The patient's medical history may reveal
hepatic or renal dysfunction, local trauma to
the skin, infection, anxiety or other
psychiatric condition

 The early lesion is red, and

may show a variable
urticarial component
All lesions are pigmented
Crust and scale may cover
recently excoriated lesions,
and there is an irregular
ring of hyperpigmentation
immediately around the
nodules

 The lesions are usually grouped, and

numerous, but vary in number
They usually develop initially on
the distal parts of the limbs & are
worse on the extensor surfaces
There are crises of pruritus of
intense severity
New nodules develop from time to
time, and existing nodules may remain
pruritic indefinitely, although some may
regress spontaneously to leave scars. The
disease runs a very protracted course

Treatment
Local applications are of little value, but
direct injection of the nodules with a steroid
such as triamcinolone is often helpful
Thalidomide is probably the most effective
treatment, if it is not contraindicated by the
risk of pregnancy
Menthol, capsaicin cream, and topical
anesthetics are some other topical agents
used to reduce pruritus

 Cyclosporin, azathioprine and topical

capsaicin have been used with success in
some cases
UV-B or PUVA may be beneficial for
severe pruritus
A thorough assessment of the patient's
emotional state is desirable, and
tranquillizers may provide relief in some
cases

 Surgical Care

Cryotherapy with liquid nitrogen

helps reduce pruritus and flatten
lesions
Pulsed dye laser therapy may help
reduce the vascularity of individual
lesions.

Erythroderma

 It is a scaling erythematous dermatitis

involving 90% or more of the cutaneous
surface

Etiology

The most common causes of ED are

(ID-SCALP(:
Idiopathic(red man syndrome) - 30%
Drug allergy(Allopurinol, aspirin,
anticonvulsants, barbiturates, captopril,
cefoxitin, chloroquine, chlorpromazine,
cimetidine, lithium, griseofulvin,
nitrofurantoin, omeprazole) - 28%
Different types of eczema - 15%
Lymphoma and leukemia - 14%
Psoriasis - 8%

Less common causes

Dermatophytosis
Lichen planus
Lupus erythematosus
Pityriasis rubra pilaris
Pemphigus foliaceus and pemphigoid

 An increased skin blood perfusion occurs

resulting in heat loss and hypothermia and
possible high-output cardiac failure
Fluid loss by transpiration is increased.
The situation is similar to that observed in
patients following burns (negative nitrogen
balance characterized by edema,
hypoalbuminemia, loss of muscle mass)

 A marked loss of exfoliated scales occurs

that may reach 20-30 g/d. This contributes to
the hypoalbuminemia commonly observed in
ED. Hypoalbuminemia results, in part, from
decreased synthesis or increased
metabolism of albumin
Edema is a frequent finding, probably
resulting from fluid shift into the extracellular
spaces

Clinically
Patients may have a history of the primary
disease (e.g. psoriasis, atopic dermatitis)
or drug use
Pruritus is a prominent and frequent
symptom and commonly results in
excoriations. Malaise, fever, and chills may
occur

 Patients often present with

generalized erythema
Scaling appears 2-6 days
after the onset of erythema,
usually starting from flexures
When ED persists for weeks,
hair may shed; nails may become ridged
and thickened and also may shed
Periorbital skin may be inflamed and
edematous, resulting in ectropion

 Idiopathic ED is characterized by marked

palmoplantar keratoderma, dermatopathic
lymphadenopathy, and a raised level of
serum IgE and is more likely to persist
than other types
Residual signs of the original disease may
be found e.g.:
- Islands of sparing in PRP
- Few typical psoriatic plaques in
psoriasis
- Papules or oral lesions of lichen planus
- Superficial blisters of pemphigus
foliaceus

Investigations
If the cause of ED is in doubt, survey
patients for occult tumors
Primary disease may be evident by skin
biopsy

Treatment
Discontinue all unnecessary medications.
Carefully monitor and control fluid intake,
since patients can dehydrate or go into
cardiac failure; monitor body temperature,
since patients may become hypothermic
Apply tap waterwet dressings (made from
heavy mesh gauze); change every 2-3
hours. Apply intermediate-strength topical
steroids (e.g. betamethasone) beneath wet
dressings

 Suggest a tepid bath (may be comforting)

once or more daily between dressing
changes. Reduce frequency of dressings
and gradually introduce emollients
between dressing applications as ED
improves
Use systemic antibiotics if signs of
secondary infection are observed

 Antihistamines help reduce pruritus and

provide needed sedation
Systemic steroids may be helpful in some
cases but should be avoided in suspected
cases of psoriasis and staphylococcal
scalded skin syndrome
Ensure adequate nutrition with emphasis
on protein intake