Case Presentation:
A 42-year-old woman presented with a 14-year history of severely itchy
skin lesions. The lesions were originally mildly pruritic, later
progressing to severe pruritus with associated burning discomfort and
purulent discharge. The patient had therapy with topical and oral
corticosteroids by a number of physicians with no improvement. She
subsequently developed Cushing syndrome from systemic corticosteroids.
She presented to the current authors with diffuse, nodular lesions
covering most of her body. Examination revealed indurated,
hyperpigmented nodules with perilesional erythema [Figure 1].
Lesional biopsy demonstrated marked hyperkeratosis, focal parakeratosis,
patchy hypergranulosis, acanthosis, papillomatosis, spongiosis, and
exocytosis. A perivascular infiltrate and eosinophils with vertically
oriented fibrosis of dermal tissue was seen [Figure 3]. A subsequent
diagnosis of prurigo nodularis was made. To treat the lesions, she
underwent 19 total biweekly UVB phototherapy sessions over the next
three months, each lasting 70 seconds. An initial dose of 3.5
J/cm2 was applied, and increased by 0.05-0.1 J each
visit. The lesions were also treated with adjuvant cryotherapy and
intralesional corticosteroids at monthly intervals. Triamcinolone 10-80
mg/ml was injected, with dose depending on lesion size and severity.
Following three months of this regimen, the appearance of her lesions
greatly improved [Figure 2]. She endorsed similar improvement in
associated symptoms.