Clinical and Histopathological Evaluation of Prurigo Nodularis

Clinical and Histopathological Evaluation of Prurigo Nodularis

1Khalifa E. Sharquie MD, PhD, FRCP Edin, 2Safa Ibrahim MD

1Department of Dermatology, College of Medicine, University of Baghdad. Iraqi and Arab Board for Dermatology & Venereology, Baghdad Teaching Hospital, Medical City, Baghdad, Iraq.
2Center of Dermatology, Medical City Teaching Hospital.

Background: Prurigo nodularis (PN) is a well-defined chronic recognized entity as a cause of severe chronic itching. However, this medical problem is not well studied and evaluated previously in Iraqi population.

Objective: To do full clinical and histopatholgical evaluation of patient with PN.

Patients and methods: This study is an observational cross sectional that was conducted at the Center of Dermatology, Medical City Teaching Hospital. All cases with classical PN and localized variant where collected. Full clinical evaluation was carried out. Biopsies were taken from 10 patients out of 50 with prurigo nodularis processed and stained with Hematoxylin and Eosin.

Results: Fifty patients were included, there were 22 (44%) males and 28 (56%) females ,their  ages ranged  from  less than 20-60 years with mean ± SD of  age (40 ± 16) years .The common associated disease was atopic dermatitis in 36 (72%)  patients, while family history of disease was seen in 24 (48%) patients, psychological factor  was seen in 30 (60%) patients . The clinical picture was excoriated nodular lesions commonly on limbs with symmetrical fashion in 40 (80%) of cases while localized pattern was detected in 10 (20%) of patients. Histopatholgical evaluation in ten patients had shown hyperkeratosis (100%), acanthosis (60%), and pseudoepithelamatous hyperplasia (40%). Eosinophils were seen in one patient.

Conclusion: This study showed classical prurigo nodularis in 80% of cases while localized in 20% of the patients. It is a disease of middle age patients, more in females than males. Family and personal history of atopic dermatitis was a high finding the histopathology is typical of prurigo nodularis with sparse eosinophils.

Keywords:Prurigo nodularis; Histopathology; Hematoxylin and Eosin stain.

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How to cite this article:
Khalifa E. Sharquie, Safa Ibrahim.Clinical and Histopathological Evaluation of Prurigo Nodularis. American Journal of Dermatological Research and Reviews, 2020, 3:27. DOI: 10.28933/ajodrr-2020-05-1105


1. Tsianakas A, Zeidler C, Riepe C, Ständer S. Pru-rigo nodularis – an update on important disease. Journal of the Egyptian Women’s Dermatologic Society 2016 13 (3): 119–124.
2. Iking A, Grundmann S, Chatzigeorgakidis E, Phan NQ, Klein D, Ständer S. Prurigo as a symptom of atopic and non-atopic diseases: aetiological survey in a consecutive cohort of 108 patients. J Eur Acad Dermatol Venereol 2013; 27:550–557.
3. Mullins TB, Sonthalia S. Prurigo Nodularis. In: Stat Pearls Internet. Treasure Island (FL): StatPearls Publishing; 2019. Available from:
4. Furue M, Yamazaki S, Jimbow K, Tsuchida T, Amagai M, Tanaka T, et al. Preva-lence of dermatological disorders in Japan: a nationwide, crosssectional, seasonal, multicen-ter, hospital-based study. J Dermatol 2011; 38:310–320.
5. Thapa DP, Jha AK, Kharel C, Shrestha S. Erma-tological problems in geriatric patients: a hospi-tal based study. Nepal Med Coll J 2012; 14:193–195.
6. Amer A, Fischer H. Prurigo nodularis in a 9-year-old girl. Clin Pediatr (Phila) 2009; 48:93–95.
7. Eigelshoven S, Homey B. Prurigo nodularis. CME Dermatol 2009; 4:140–155.
8. Schuhknecht B, Marziniak M, Wissel A, Phan NQ, Pappai D, Dangelmaier J, et al. Reduced intraepidermal nerve fibre density in lesional and nonlesional prurigo nodularis skin as a potential sign of subclinical cutaneous neuropathy. Br J Dermatol 2011; 165: 85–91.
9. Groneberg DA, Serowka F, Peckenschneider N, Artuc M, Grutzkau A, Fischer A, et al. Gene ex-pression and regulation of nerve growth factor in atopic dermatitis mast cells and the human mast cell line-1. J Neuroimmunol 2005; 161: 87–92.
10. Raap U, Wichmann K, Bruder M, Sta¨nder S, Wedi B, Kapp A, Werfel T. Correlation of IL-31 serum levels with severity of atopic dermatitis. J Allergy Clin Immunol 2008; 122:421–423.
11. Arai I, Tsuji M, Takeda H, Akiyama N, Saito S. A single dose of interleukin-31 (IL-31) causes con-tinuous itch-associated scratching behaviour in mice. Exp Dermatol 2013; 22: 669–671.
12. Murota H, Kitaba S, Tani M, Wataya-Kaneda M, Azukizawa H, Tanemura A, et al. Impact of seda-tive and non-sedative antihistamines on the im-paired productivity and quality of life in patients with pruritic skin diseases. Allergol Int 2010; 59: 345–354.
13. Bobko S, Zeidler C, Osada N, Riepe C, Pflei-derer B, PogatzkiZahn E, et al. Intraepidermal nerve fibre density is decreased in lesional and interlesional prurigo nodularis and reconstitutes on healing of lesions. Acta Derm Venereol 2016; 96: 404–406.
14. Perez GL, Peters MS, Reda AM, Butterfield JH, Peterson EA, Leiferman KM. Mast cells, neutro-phils, and eosinophils in prurigo nodularis. Arch Dermatol 1993; 129(7):861-865.
15. 74.Sandbank M . Cutaneous nerve lesions in prurigo nodularis .Electron microscopic study of two patients.J Cutan Pathol.1976.3(3):125-32.16. Matsumura S, Terao M, Murota H, Katayama I. Th2 cytokines enhance TrkA ex-pression, upregulate proliferation, and down-regulate differentiation of keratinocytes. J Der-matol Sci 2015; 78: 215–223.
16. Schedel F, Schu¨rmann C, Metze D, Sta¨nder S. Prurigo clinical definition and classification arti-cle in German. Hautarzt 2014; 65:684– 690.
17. Pugliarello S, Cozzi A, Gisondi P, Girolomoni G. Phenotypes of atopic dermatitis. J Dtsch Der-matol Ges 2011; 9: 12–20.
18. Al-Salhi W, Alharithy R. Pemphigoid nodularis. J Cutan Med Surg 2015; 19: 153–155.
19. Solak B, Acikgoz SB, Sipahi S, Erdem T. Epi-demiology and determinants of pruritus in pre-dialysis chronic kidney disease patients. Int Urol Nephrol 2016; 48: 585–591.
20. Hayani K, Weiss M, Weisshaar E. Clinical find-ings and provision of care in haemodialysis pa-tients with chronic itch: new results from the German Epidemiological Haemodialysis Itch Study. Acta Derm Venereol 2016; 96: 361–366.
21. Tseng HW, Ger LP, Liang CK, Liou HH, Lam HC. High prevalence of cutaneous manifestations in the elderly with diabetes mellitus: an institution-based cross-sectional study in Taiwan. J Eur Acad Dermatol Venereol 2015; 29: 1631–1635.
22. Mettang T, Vonend A, Raap U. Prurigo nodularis bei Dermatosen und systemischen Erkrankungen. Hautarzt 2014; 65: 697–703.
23. Gieler U, Consoli SG, Tomas-Aragones L, Linder DM, Jemec GB, Poot F, et al. Self-inflicted le-sions in dermatology: terminology and classifi-cation – a position paper from the European Society for Dermatology and Psychiatry (ESDaP). Acta Derm Venereol 2013; 93: 4–12 .
24. Siepmann D, Lotts T, Blome C, Braeutigam M, Phan NQ, ButterfassBahloul T, et al. Evaluation of the antipruritic effects of topical pimecroli-mus in nonatopic prurigo nodularis: results of a randomized, hydrocortisone-controlled, double-blind phase II trial. Dermatology 2013; 227:353–360.
25. Richards RN. Update on intralesional steroid: focus on dermatoses. J Cutan Med Surg 2010; 14:19–23.
26. Zeidler C, Lüling H, Dieckhöfer A, Osada N, Schedel F, Steinke S, et al. Capsaicin 8% cuta-neous patch: a promising treatment for brachi-oradial pruritus? Br J Dermatol 2015; 172:1669–1671.
27. Schulz S, Metz M, Siepmann D, Luger TA, Maurer M, Sta¨nder S. Antipruritic efficacy of a high-dosage antihistamine therapy. Results of a retrospectively analysed case series. Hautarzt 2009; 60:564–568.
28. Shintani T, Ohata C, Koga H, Ohyama B, Hama-da T, Nakama T, et al. Combination therapy of fexofenadine and montelukast is effective in prurigo nodularis and pemphigoid nodularis. Dermatol Ther 2014; 27:135–139.
29. Bruni E, Caccialanza M, Piccinno R. Photother-apy of generalized prurigo nodularis. Clin Exp Dermatol 2010; 35:549–550.
30. Hammes S, Hermann J, Roos S, Ockenfels HM. UVB 308 nm excimer light and bath PUVA: combination therapy is very effective in the treatment of prurigo nodularis. J Eur Acad Der-matol Venereol 2011; 25:799–803.
31. Mazza M, Guerriero G, Marano G, Janiri L, Bria P, Mazza S. Treatment of prurigo nodularis with pregabalin. J Clin Pharm Ther 2013; 38:16–18.
32. Baron A. AWMF guidelines for diagnostics and therapy in neurology: pharmacological, not in-terventional therapy of chronic neuropathic pain; 2012. Available at:
33. Tefferi A, Fonseca R. Selective serotonin reuptake inhibitors are effective in the treatment of polycythemia vera-associated pruritus. Blood 2002; 99:2627.
34. Siepmann D, Luger TA, Sta¨nder S. Antipruritic effect of cyclosporine microemulsion in prurigo nodularis: results of a case series. J Dtsch Dermatol Ges 2008; 6:941–946.
35. Spring P, Gschwind I, Gilliet M. Prurigo nodu-laris: retrospective study of 13 cases managed with methotrexate. Clin Exp Dermatol 2014; 39:468–473.
36. Andersen TP, Fogh K. Thalidomide in 42 pa-tients with prurigo nodularis Hyde. Dermatology 2011; 223:107–112.
37. Liu H, Gaspari AA, Schleichert R. Use of le-nalidomide in treating refractory prurigo nodu-laris. J Drugs Dermatol 2013; 12:360–361.
38. Halvorsen JA, Aaseb W. Oral tacrolimus treat-ment of pruritus in prurigo nodularis. Acta Derm Venereol 2015; 95:866–867.
39. Pereira MP, Basta S, Moore J, Ständer S. Pruri-go nodularis: a physician survey to evaluate cur-rent perceptions of its classification, clinical ex-perience and unmet need. J Eur Acad Dermatol Venereol 2018; 32(12):2224-2229.
40. Al-Waiz MM,Al-Hamami IA,Maluki AH. AClini-co,pathological study of prurigo nodularis in Iraqi patients. } thesis {.Baghdad :Submitted to the Iraqi Board of health Specializations in Der-matology and Venerology ;1997.
41. Akarsu S, Ozbagcivan O, Ilknur T, Semiz F, Inci BB, Fetil E. Xerosis cutis and associated co-factors in women with prurigo nodularis. An Bras Dermatol 2018; 93(5):671–679..
42. Al-Waiz MM, Maluki AH. Squamous cell carci-noma complicating prurigo nodularis. Saudi Med J 2000; 21(3):300-301..
43. Rambhia PH, Levitt JO. Recalcitrant prurigo nodularis treated successfully with dupilumab. JAAD Case Rep 2019; 5(5):471–473.
44. Tan WS, Tey HL. Extensive prurigo nodularis: characterization and etiology. Dermatology 2014; 228(3):276-280..
45. Ständer S, Stumpf A, Osada N, Wilp S, Chat-zigeorgakidis E, Pfleiderer B. Gender differ-ences in chronic pruritus: women present differ-ent morbidity, more scratch lesions and higher burden. Br J Dermatol 2013; 168(6):1273-1280.
46. Prurigo Nodularis. American Osteopathic Col-lege of Dermatology.2018. Available at:
47. Oakley A. Nodular prurigo. DermNet NZ. 2014. Available at:
48. Prak AH, De la Rosa KM. Prurigo Nodularis. Medscape Reference 2017. Available at:
49. Weigelt N, Metze D, Ständer S. Prurigo nodu-laris: systematic analysis of 58 histological cri-teria in 136 patients. J Cutan Pathol 2010; 37(5):578586.

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