Treatment for Prurigo Nodularis

First-Line Treatments

The British Journal of Dermatology recommends potent topical corticosteroids, such as clobetasol propionate 0.05%, as first-line treatment for prurigo nodularis, with treatment limited to avoid side effects 1
Topical menthol preparations may provide counter-irritant effects that help relieve pruritus in patients with prurigo nodularis 2

The British Journal of Dermatology suggests non-sedating antihistamines, such as fexofenadine 180 mg or loratadine 10 mg, or mildly sedative agents, such as cetirizine 10 mg, as second-line treatment for prurigo nodularis 3, 4, 2
Consider combination of H1 and H2 antagonists, such as fexofenadine and cimetidine, for enhanced effect in patients with prurigo nodularis 4, 1
Phototherapy, including narrowband UVB or broadband UVB, can provide symptomatic relief for patients with prurigo nodularis 1

The British Journal of Dermatology recommends gabapentinoids, such as pregabalin 25-150 mg daily or gabapentin 900-3600 mg daily, as third-line treatment for neuropathic pruritus in patients with prurigo nodularis 4, 3
Antidepressants, including paroxetine, fluvoxamine, and mirtazapine, may help reduce pruritus intensity in patients with prurigo nodularis 4
Aprepitant, a neurokinin-1 receptor antagonist, has shown efficacy in reducing pruritus in patients with prurigo nodularis 4, 1

The British Journal of Dermatology advises against using crotamiton cream, topical capsaicin, and calamine lotion for generalized pruritus in patients with prurigo nodularis due to lack of significant antipruritic effect 5, 4, 2
Always investigate for potential underlying systemic diseases, such as renal disease, liver disease, lymphoma, or iron deficiency, that may be causing or exacerbating prurigo nodularis in patients 3, 5

Reassess treatment efficacy after 2 weeks; if reactions worsen or do not improve, proceed to next treatment option, as recommended by the Annals of Oncology 3
For grade 3 or intolerable grade 2 pruritus, consider treatment interruption and more aggressive management, according to the Annals of Oncology 3