Dear Doctor
I am suffering from extensive itching on my body, mostly on legs. These are now like big black spots on my body. I consulted my doctor and he referred skin biopsy.
After seeing the report he said there is nothing to worry and he just said to me to take
Atarax 25 (hydroxyzine) tablets for now.
Please review my report and let me know your views. Thanks.
Dear Patient
Prurigo Nodularis Histolopathology
Histology findings of skin biopsies done on prurigo nodularis include:
1. Hyperkeratosis (hypertrophy or thickening of the stratum corneum layer of the skin)
2. Parakeratosis (retention of nuclei in the keratinocytes of the stratum corneum)
3. Acanthosis (hyperplasia of the stratum spinosum)
4. Accentuated and irregular rete ridges ( epidermal thickening that extend downward between the dermal papillae)
5. Infiltrate of neutrophils, eosinophils, hisitiocytes and monocytes into the dermis
6. Thickened collagen bundles and nerve fibers in the dermis
This is in agreement with what the pathologist found when they examined your skin biopsy specimen.
Prurigo Nodularis Treatment
The treatment of prurigo nodularis can be quite challenging and it involves the use of:
Psychotherapy
Patients should be advised to stop touching and scratching the lesions. Habit reversal therapy to stop the itch-scratch cycle is also beneficial for treating prurigo nodularis.
Corticosteroids
Corticosteroids creams are applied on the skin to treat prurigo nodularis since they reduce the inflammation and itch. Examples include like clobetasol (Temovate).
The application of steroids has to be monitored closely by the doctor since it can cause many side effects like thinning of the skin (skin atrophy) and streaking of the skin (skin striae) as well as internal complications.
Triamcinolone acetonide is a steroid which is injected into resistant prurigo nodules to soften and flatten them.
Antihistamines
Antihistamines control the itch by blocking the effects of the released histamine. Examples include the non-sedating fexofenadine (Allegra) and loratadine (Claritin) as well as the less sedating cetirizine (Zyrtec). The sedating diphenhydramine (Benadryl), chlorpheniramine (Chlor-Trimeton) and hydroxyzine (Atarax) are also used to reduce the itch especially if it disturbs sleep. Hydroxyzine can also be used as an anxiolytic and it is therefore a good antihistamine for prurigo nodularis.
Topical Medications
Other medications applied on the skin to reduce the itch of prurigo nodularis include:
- Pramoxine (Itch-X)
- Capsaicin cream (Zostrix)
- Vitamin D3 analogs ointment like Calcipotriene (Dovonex)
- Topical immunomodulators are substances which alter the response of the immune system. These medications which are also known as calcineurin inhibitors also reduce inflammation. They are used on patients with prurigo nodularis who do not respond to steroids or those who have thin skin since this makes them poor candidates for using topical steroids. Examples include tacrolimus (Protopic) and pimecrolimus (Elidel). Side effects of calcineurin inhibitors include burning or painful sensations and making the skin more sensitive to sunlight.
Cryotherapy
Cryotherapy which is freezing with liquid nitrogen is used to flatten the lesions and reduce the itch.
Conclusion
I would have loved to see a picture of your prurigo nodularis lesions. Since I do not have it, I suggest you continue with the Aterax and try to stop touching or scratching the lesions.
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