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.