PRURIGO

Prurigo is derived from the Latin and means itch, which simply refers to the
common feature shared by all pruriginous diseases, a sometimes intractable
pruritus. The combination of pruritus and associated skin lesions, produced by
scratching, is known as prurigo.

The cause of prurigo is unknown. It is unclear why in some clinical settings

pruritus leads to excoriations, and in others to the development of dome- shaped
papules. Many different unrelated diseases are lumped together under the rubric of
prurigo. All can be treated in the same way with systemic antihistamines and in
some instances with topical and systemic corticosteroids.1

There will be two type of prurigo discussed in this paper: prurigo simplex
(nodularis) and pruriginous dermatoses.

1. PRURIGO SIMPLEX (NODULARIS)

Prurigo nodularis, which was previously believed to be a separate disease entity,

is now believed to be a secondary reaction to scratching which is preceded by
severe pruritus affecting inflamed or healthy skin. Synonyms for prurigo nodularis
include prurigo nodularis (Hyde), prurigo simplex chronica, and lichen obtusus
corneus. Prurigo nodularis is thus considered a clinical expression of chronic
pruritus. The primary symptom with which patients present is usually massive,
and sometimes excruciating pruritus. There is usually a symmetrical pattern of
involvement, mainly on the extensor aspects of the extremities, the shoulders, and
the chest and sacral regions with the appearance of typical lesions. 2

Prurigo nodularis affects women more often than men. The disease commonly
affects middle-aged or older patients, although it can also occur in children There
are no known genetic factors. There are as yet no figures available on the
incidence and prevalence of prurigo nodularis.3

In most patients a cause is not identifiable, although there are exceptions, such as
for instance in prurigo with underlying systemic disease. Prurigo nodularis
divided into two forms:

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 early-onset atopic disease in which the median age of initial manifestation
is 19 years and there is a close association with atopic dermatitis and
environmental allergens, and
late-onset non-atopic disease in which the median age of initial
manifestation is 48 years and there is no association with environmental
allergens.

1.1 Clinical presentation

The primary symptom with which patients present is usually massive, and
sometimes excruciating pruritus with a sharply demarcated, tough, mildly
erythematous nodule. There is usually a symmetrical pattern of involvement,
mainly on the extensor aspects of the extremities, the shoulders, and the chest and
sacral regions with the appearance of typical lesions. The face, palms of the
hands, and plantar surfaces of the feet are usually not affected and there is never
involvement of the mucous membranes. The primary lesion manifests.

As a result of excruciating pruritus, patients often scratch intensely leading to gray

or purple and sometimes verruciform keratotic areas, excoriations, crater-like
ulcerations, and hemorrhagic crusts. After the lesions heal, residual lesions are left
behind with post-inflammation hyperpigmentation or areas of hypopigmentation
and scarring. The number of lesions can range from a few solitary lesions to
hundreds of lesions.

The development of nodules first occurs as a result of intense scratching.

Typically there is an area of skin that is unaffected which the patient cannot reach,
such as the middle of the back. This characteristic feature of prurigo nodularis is
referred to as the butterfly sign and underscores the significance of the
mechanical trauma for the development of characteristic lesions. The development
of areas of keratosis, excoriation, and ulceration on primary lesions is attributed to
the constant irritation caused by scratching. The scratching of a lesion produces
only temporary relief from pruritus, which quickly starts again, leading to an
itch-scratch-cycle which causes the nodules to persist and leads to secondary
lesions.

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Due to the simultaneous appearance of recent and older lesions, patients usually
present with a polymorphous appearance consisting of recent nodules,
excoriations, or crater-like ulcerations and residual lesions such as areas of
hypopigmentation or hyperpigmentation as well as scarring.

Under marked hyperkeratosis with focal parakeratosis there is also irregular

acanthosis. At the surface, around vessels and in interstitial spaces there is a
moderately dense infiltrate of lymphocytes, isolated eosinophilic granulocytes,
mast cells, macrophages, dermal dendritic cells, melanophages, or
hemosiderophages with extravasal erythrocytes. Eosinophilic granulocytes with
degranulation may also be found in patients with accompanying atopic diathesis.
If there are erosions or excoriations, crusting around the margin with exudation
and parakeratosis are typically seen and there are plasma cells and neutrophils. 4

1.2 Diagnosis

Given that the development of nodules in prurigo nodularis is presumably a

secondary reactive response to persistent scratching to relieve pruritus, an
underlying pruritic disorder must be ruled out, consistent with chronic pruritus.
This includes skin disorders as well as endocrine and metabolic disorders,
hematological and lymphoproliferation diseases, infectious diseases, parasitic
diseases, and neurological and psychogenic diseases. In addition, certain
medications can cause and sustain pruritus. Diagnosis is based on the taking of a
thorough family history and careful clinical examination.5

1.3 Differential diagnoses

Neurodermatitis
Dermatitis herpetiformis
Pruriginous dermatoses.
Papular urticaria: insect bites.6

1.4 Therapy

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Therapy must be done for months until years which can result in full or half
remission. Most effective are high-potency corticosteroids under occlusion or
intralesional corticosteroids such as triamcinolone asetoid, coupled with systemic
antihistamines. 6

2. PRURIGINOUS DERMATOSES

These are different diseases associated with pruritus and papular lesions. This
condition shows urticarial multiform, where some the papular lessions are
accompanied by wheals, eczematization and lichenifecation.7

2.1 There are some clinical type for pruriginous dermatose: 7

1. Besniers prurigo: This is chronic lichenified flexural lesions and is

considered as a type of atopic dermatitis.

2. Hutchinsons summer prurigo: this is an actinic type precipitated by

excessive exposure to sunlight.

3. Prurigo Chronica Multiformis: presents with prurigo nodules,

lichenification, eczematization, enlarged lymph nodes and esinophilia.

4. Hebras prurigo

Hebras prurigo is now rarely diagnosed and its status is

questionable.
Most cases occurred in atopic subjects and the role of poor
nutritional and hygienic conditions were considered as
predisposing factors.
The possibility that some cases represent papular urticaria modified
in an atopic subject must be considered.
5. Prurigo mitis :
This type begins early in childhood, Characterized by uniform type
of small rounded, flesh colored or erythematous,
Severely pruritic, flat-topped papule, surmounted by a vesicle.

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 Severe itching lead to excoriation, eczematization and on healing
of lesions, they may leave skin scarring.
6. Prurigo pigmentosa:
The disorder is more common in adults, a type of uncommon
pruritic disorder that heals with distinctive hyperpigmentation with
an onset in the spring and summer months.
Usually accompanied by secondary infection and frequently seen
in HIV patients. Secondary infection is common.
The characteristic lesions are found on the trunk and neck.
Intensely pruritic inflammatory papules usually favoring breasts
and anterior chest; often arranged in reticular pattern. Heal with
striking post inflammatory hyperpigmentation.
Clinical feature present as itchy red papules that occasionally
coalesce to a reticular pattern. Hard, excoriated prurigo papule
associated with lichenifecation. Later they are superseded by a
reticular hyperpigmentation. Pustulation and pitted scars are
common manifestations due to the severe scratching and
excoriation of the lesion.

2.2 Diagnosis

As in prurigo nodularis, diagnosis in pruriginous dermatoses is also based on the

taking of a thorough family history and careful clinical examination.5

2.3 Differential Diagnosis

Dermatitis herpetiformis
Neurodermatitis
Chronic atopic dermatitis
Herpes gestationis.7

2.4 Therapy

Treatment for prurigo are symptomatic. Avoidance to trigerring factors such as

isect bites, over sunlight and cold exposure is highly recommended. For

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medication, there are some medication that can we used for treating the patients
with this conditions, such as:

1. Anti histamine: mebidrolyn napadisilic, loratadin, CTM

2. corticosteroids topical and systemic: prednisone, deroxymelosone
cream/ointment, methyl prenisolon.
3. Intralesional injection: injection in the nodul lesion with steroid
(triamcinolone)
4. Tranquilizer: used for patient with emotional disorder.7

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 REFERENCES

1. Sibylle Eigelshoven, Bernhard Homey. Prurigo nodularis. CME Dermatol

2009; 4(3): 140-155
2. Braun-Falco O, Plewig G, Wolff HH, Burgdorf WHC, Landthaler M
(Hrsg). Dermatologie und Venerologie. Berlin, Heidelberg, New York:
Springer 2005.
3. Amer A, Fischer H. Prurigo nodularis in a 9-year-old girl. Clin Pediatr
(Phila) 2009; 48: 93-5.
4. Kerl H, Garbe C, Cerroni L, Wolff HH (Hrsg). Histopatho- logie der Haut.
Berlin, Heidelberg, New York: Springer 2003.
5. Stnder S, Reinhardt HW, Luger TA. Topical cannabinoid agonists. An
effective new possibility for treating chronic pruritus. Hautarzt 2006; 57:
8017.
6. Ido T, Takashima W, Kiyohara T, Kumakiri M, Kaniwa M. Prurigo
nodularis occurred in a patient with an allergy to pyridine derivative in
desk mat. Contact Dermatitis 2008; 58: 2501.
7. Thieme Clinical Companions Dermatologi. Pruritus and Prurigo. Sterry,
Dermatology 2006; 20: 328-331.