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Yook HJ, Lee JH. Prurigo Nodularis: Pathogenesis and the Horizon of Potential Therapeutics. Int J Mol Sci 2024; 25:5164. [PMID: 38791201 PMCID: PMC11121340 DOI: 10.3390/ijms25105164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 05/26/2024] Open
Abstract
Chronic pruritus that lasts for over 6 weeks can present in various forms, like papules, nodules, and plaque types, with prurigo nodularis (PN) being the most prevalent. The pathogenesis of PN involves the dysregulation of immune cell-neural circuits and is associated with peripheral neuropathies, possibly due to chronic scratching. PN is a persistent and challenging condition, involving complex interactions among the skin, immune system, and nervous system. Lesional skin in PN exhibits the infiltration of diverse immune cells like T cells, eosinophils, macrophages, and mast cells, leading to the release of inflammatory cytokines and itch-inducing substances. Activated sensory nerve fibers aggravate pruritus by releasing neurotransmitters, perpetuating a vicious cycle of itching and scratching. Traditional treatments often fail, but recent advancements in understanding the inflammatory and itch transmission mechanisms of PN have paved the way for innovative therapeutic approaches, which are explored in this review.
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Affiliation(s)
| | - Ji Hyun Lee
- Department of Dermatology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, #222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea
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Tutka K, Żychowska M, Żaczek A, Maternia-Dudzik K, Pawełczyk J, Strapagiel D, Lach J, Reich A. Skin Microbiome in Prurigo Nodularis. Int J Mol Sci 2023; 24:ijms24087675. [PMID: 37108838 PMCID: PMC10146575 DOI: 10.3390/ijms24087675] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
Prurigo nodularis (PN) is a chronic condition characterized by the presence of nodular lesions accompanied by intense pruritus. The disease has been linked to several infectious factors, but data on the direct presence of microorganisms in the lesions of PN are scarce. The aim of this study was to evaluate the diversity and composition of the bacterial microbiome in PN lesions by targeting the region V3-V4 of 16S rRNA. Skin swabs were obtained from active nodules in 24 patients with PN, inflammatory patches of 14 patients with atopic dermatitis (AD) and corresponding skin areas of 9 healthy volunteers (HV). After DNA extraction, the V3-V4 region of the bacterial 16S rRNA gene was amplified. Sequencing was performed using the Illumina platform on the MiSeq instrument. Operational taxonomic units (OTU) were identified. The identification of taxa was carried out using the Silva v.138 database. There was no statistically significant difference in the alpha-diversity (intra-sample diversity) between the PN, AD and HV groups. The beta-diversity (inter-sample diversity) showed statistically significant differences between the three groups on a global level and in paired analyses. Staphylococcus was significantly more abundant in samples from PN and AD patients than in controls. The difference was maintained across all taxonomic levels. The PN microbiome is highly similar to that of AD. It remains unclear whether the disturbed composition of the microbiome and the domination of Staphylococcus in PN lesions may be the trigger factor of pruritus and lead to the development of cutaneous changes or is a secondary phenomenon. Our preliminary results support the theory that the composition of the skin microbiome in PN is altered and justify further research on the role of the microbiome in this debilitating condition.
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Affiliation(s)
- Klaudia Tutka
- Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszów, Poland
| | - Magdalena Żychowska
- Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszów, Poland
| | - Anna Żaczek
- Department of Microbiology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszów, Poland
| | - Karolina Maternia-Dudzik
- Department of Microbiology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszów, Poland
| | - Jakub Pawełczyk
- Laboratory of Genetics and Physiology of Mycobacterium, Institute of Medical Biology, Polish Academy of Sciences, 90-235 Łódź, Poland
| | - Dominik Strapagiel
- Biobank Laboratory, Department of Oncobiology and Epigenetics, Faculty of Biology and Environmental Protection, University of Lodz, 90-235 Łódź, Poland
| | - Jakub Lach
- Biobank Laboratory, Department of Oncobiology and Epigenetics, Faculty of Biology and Environmental Protection, University of Lodz, 90-235 Łódź, Poland
| | - Adam Reich
- Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszów, Poland
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Dermatological manifestations of hematologic neoplasms. Part II: nonspecific skin lesions/paraneoplastic diseases. An Bras Dermatol 2023; 98:141-158. [PMID: 36682966 PMCID: PMC9984718 DOI: 10.1016/j.abd.2022.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/22/2022] [Accepted: 08/09/2022] [Indexed: 01/21/2023] Open
Abstract
Cutaneous manifestations occur in the course of hematologic malignancies and precede, accompany or occur late in relation to the diagnosis. They result from paraneoplastic phenomena, tumor infiltrations, immunosuppression resulting from the hematologic disease itself or its treatment. The dermatologist must be aware of these conditions that may be helpful both in the diagnosis of the underlying disease and in reducing patient morbidity. This review (part II) addresses the paraneoplastic dermatological changes associated with systemic hematologic malignancies.
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Espiñeira Sicre J, Docampo Simón A, Silvestre Salvador J. [Translated article] Chronic Nodular Prurigo: A Retrospective Study of 74 Cases. ACTAS DERMO-SIFILIOGRAFICAS 2022. [DOI: 10.1016/j.ad.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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Espiñeira Sicre J, Docampo Simón A, Silvestre Salvador J. Prurigo crónico nodular: Estudio retrospectivo de 74 casos. ACTAS DERMO-SIFILIOGRAFICAS 2022; 113:866-873. [DOI: 10.1016/j.ad.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/18/2022] [Accepted: 05/22/2022] [Indexed: 10/18/2022] Open
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Williams KA, Roh YS, Brown I, Sutaria N, Bakhshi P, Choi J, Gabriel S, Chavda R, Kwatra SG. Pathophysiology, diagnosis, and pharmacological treatment of prurigo nodularis. Expert Rev Clin Pharmacol 2020; 14:67-77. [PMID: 33191806 DOI: 10.1080/17512433.2021.1852080] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction: Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intensely pruritic, hyperkeratotic nodules distributed on the trunk and extensor surfaces of the extremities. PN has a profoundly negative impact on sleep and quality of life in patients with PN. There are currently no U.S. Food and Drug Administration-approved agents and patients are often recalcitrant to current therapies, highlighting the importance of further research into this severely debilitating condition. Areas covered: A PubMed search was conducted to find available literature on the pathophysiology and clinical management of PN. In this review article, we discuss the current understanding of the pathophysiology, recommended diagnostic approach, and treatment options available for PN. Expert opinion/commentary: PN is an extremely difficult condition to treat, because there is a lack of effective therapies available due to our limited understanding of its pathophysiology. Currently, available treatment options are often multimodal due to the intersection of neuroimmune etiologic factors in the pathogenesis of PN. Fortunately, as our knowledge of PN expands, novel treatments targeting specific molecular biomarkers of PN are emerging, providing hope to this long-suffering patient population.
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Affiliation(s)
- Kyle A Williams
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Youkyung S Roh
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Isabelle Brown
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Nishadh Sutaria
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Pegah Bakhshi
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Justin Choi
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
| | - Sylvie Gabriel
- 27 Galderma Presciption GBU , La Tour-dePeilz, Switzerland
| | - Rajeev Chavda
- 27 Galderma Presciption GBU , La Tour-dePeilz, Switzerland
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine , Baltimore, USA
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Practical approaches for diagnosis and management of prurigo nodularis: United States expert panel consensus. J Am Acad Dermatol 2020; 84:747-760. [PMID: 32682025 DOI: 10.1016/j.jaad.2020.07.025] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 07/03/2020] [Accepted: 07/05/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Prurigo nodularis (PN) is a chronic disease characterized by intensely pruritic, raised, nodular lesions. Because there are currently no United States Food and Drug Administration-approved therapies specifically for PN, management is highly variable, and no consensus exists on treatment regimens. OBJECTIVE To provide practical guidance to help United States dermatologists diagnose and effectively treat patients with PN. METHODS We participated in a roundtable discussion to develop consensus recommendations on diagnosis and treatment of PN from a United States perspective. RESULTS The core findings in PN are the presence of firm, nodular lesions; pruritus lasting at least 6 weeks; and a history or signs, or both, of repeated scratching, picking, or rubbing. The diagnostic workup involves a complete review of systems, considering potential systemic diseases, and assessment of disease severity, including disease burden and pruritus intensity. Treatment should be selected based on a patient's clinical presentation, comorbidities, and response to prior treatments and should address both neural and immunologic components of pruritus. LIMITATIONS Data on PN are from anecdotal or small clinical trials, and all treatments are currently used off-label. CONCLUSION An effective treatment approach for patients with PN should be based on clinical judgment and tailored to the individual needs of the patient.
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Huang AH, Williams KA, Kwatra SG. Prurigo nodularis: Epidemiology and clinical features. J Am Acad Dermatol 2020; 83:1559-1565. [PMID: 32454098 DOI: 10.1016/j.jaad.2020.04.183] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/14/2022]
Abstract
Prurigo nodularis (PN) is a chronic inflammatory skin disease characterized by intensely pruritic, hyperkeratotic nodules that favor the extensor surfaces of the extremities and the trunk. In addition to its significant impact on quality of life, many patients with PN are recalcitrant to therapy because there are currently no therapies approved by the US Food and Drug Administration. In the first article of this 2-part continuing medical education series, we describe the broader epidemiology, patient demographics, physical examination findings, and symptoms to aid in the timely recognition and diagnosis of PN. Furthermore, we quantify the burden of comorbidities in PN by discussing the broad spectrum of systemic diseases and mental health conditions that have been associated with this condition. The second article of this 2-part series focuses on the pathogenesis of PN and provides detailed algorithms for comprehensive work-up and management.
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Affiliation(s)
- Amy H Huang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Kyle A Williams
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland.
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Larson VA, Tang O, Stander S, Miller LS, Kang S, Kwatra SG. Association between prurigo nodularis and malignancy in middle-aged adults. J Am Acad Dermatol 2019; 81:1198-1201. [PMID: 30954580 DOI: 10.1016/j.jaad.2019.03.083] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/22/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Valerie A Larson
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Olive Tang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sonja Stander
- Center for Chronic Pruritus, Department of Dermatology, University Hospital Münster, Germany
| | - Lloyd S Miller
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sewon Kang
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shawn G Kwatra
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
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Dumont S, Péchère M, Toutous Trellu L. Chronic Prurigo: An Unusual Presentation of Hodgkin Lymphoma. Case Rep Dermatol 2018; 10:122-126. [PMID: 29928200 PMCID: PMC6006658 DOI: 10.1159/000489161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/10/2018] [Indexed: 12/12/2022] Open
Abstract
Background Prurigo nodularis is a condition of unknown origin defined by papulonodular eruption and intense pruritus. Hodgkin lymphoma often presents nonspecific initial symptoms. An association between systemic malignancy and cutaneous manifestations has long been documented. We report a case of prurigo nodularis as a first presentation of Hodgkin lymphoma. Case A 35-year-old woman presented with a 2-year history of pruritus. Previously diagnosed with bedbugs, the pruritus persisted even after insect eradication, with the appearance of papulonodular lesions consistent with chronic prurigo. The pruritus and the pain were refractory to all treatments. She had no past medical history or clinical, radiological, or laboratory findings. A lymphadenopathy was revealed 2 years after onset of the symptoms. Lymph node biopsy showed a nodular sclerosis Hodgkin lymphoma. The patient was initiated on chemotherapy and the skin lesions decreased. Conclusion This case report of chronic prurigo as the first manifestation of a systemic malignancy reminds us of the importance of a systematic diagnostic approach to this kind of patients initially and throughout time, especially if the symptoms do not respond to treatment. Our case may question the role of imaging examinations in the management and follow-up of a persistent prurigo nodularis.
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Affiliation(s)
- Shireen Dumont
- Internal Medicine Department, Hôpital de la Tour, Geneva, Switzerland
| | - Marc Péchère
- Department of Dermatology, Geneva University Hospital, Geneva, Switzerland
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Mettang T, Vonend A, Raap U. Prurigo nodularis bei Dermatosen und systemischen Erkrankungen. Hautarzt 2014; 65:697-703. [DOI: 10.1007/s00105-014-2755-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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