This handout is for prurigo nodularis (chronic nodular prurigo). Your care team identified this based on: chronic intense itch (>6 wk) with symmetric firm hyperkeratotic dome-shaped excoriated nodules on extensor limbs/trunk — the defining chronic-nodular-prurigo presentation (s2k chronic prurigo stander jddg 2022 pmid 36252071).
Other reasons your team may use this plan: history of repeated scratching/picking with scratch-associated pruriginous lesions — the self-perpetuating itch–scratch cycle defining chronic prurigo (s2k pmid 36252071); pre-existing itch driver (atopic dermatitis, ckd, cholestasis, thyroid disease, iron deficiency, hiv, lymphoma, neuropathic, psychogenic, drug) → pn as a secondary itch-scratch sequel (s2k pmid 36252071; chronic prurigo review pmid 37717255); severe itch with major sleep/qol/psychiatric burden refractory to topical therapy → systemic-ladder + biologic entry (chronic prurigo review pmid 37717255; qol burden whang jaad 2021 pmid 34058278).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| emollient_and_gentle_skin_care | — | — | — | S2k chronic prurigo (PMID 36252071) — liberal emollient + gentle non-soap cleansing reduces xerosis-driven itch and the threshold to scratch; the substrate of all antipruritic therapy. |
| scratch_cycle_behavioural_interruption_and_occlusion | — | — | — | S2k (PMID 36252071) + chronic prurigo review (PMID 37717255) — habit-reversal, nail care, and occlusion/bandaging physically break the self-perpetuating itch–scratch cycle; lesions will not heal while scratching continues. |
| clobetasol propionate | 0.05% ointment | topical | BID to nodules, ± occlusion; taper with healing | S2k (PMID 36252071) — high-/super-potent topical corticosteroid (often under occlusion) is first-line topical for hyperkeratotic prurigo nodules; potency matched to thickness, then step down. |
| triamcinolone acetonide | 5–10 mg/mL intralesional | intralesional | every 3–4 wk to recalcitrant nodules | S2k (PMID 36252071) — intralesional triamcinolone for individual recalcitrant thick nodules unresponsive to topical steroid; limited number per session, atrophy-aware. |
| tacrolimus | 0.1% ointment | topical | BID | S2k (PMID 36252071) — topical calcineurin inhibitor is steroid-sparing for maintenance and thinner-skin sites; transient burning common. |
| capsaicin | 0.025–0.1% cream (or high-conc patch in selected) | topical | 4–6×/day to defunctionalise cutaneous nerves | S2k (PMID 36252071) + chronic prurigo review (PMID 37717255) — topical capsaicin defunctionalises TRPV1+ cutaneous nerve fibres (the remodelled-nerve component of PN); burning limits adherence, requires frequent application. |
| hydroxyzine | 25 mg PO at night | PO | nocte PRN | S2k (PMID 36252071) — sedating antihistamine is adjunctive for SLEEP only (the nocturnal itch–scratch component), not an effective antipruritic for PN per se; elderly anticholinergic/fall caution. |
Plan: Prurigo nodularis — treat-the-driver + severity-tiered antipruritic ladder (S2k chronic prurigo 2022 / chronic prurigo review 2023)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Chronic-disease maintenance: durable scratch-cycle interruption (habit-reversal, occlusion, nail care, written plan), continued driver control (the disease relapses if the driver recurs), proactive emollient/skin-care habit, sleep + mental-health surveillance with integrated psychodermatology for excoriation/depression/anxiety, gabapentinoid renal-dose continuity, biologic interval/step-down once durably controlled, and re-evaluation of the diagnosis (CTCL/BP) if the course remains atypical. Dermatology continuity for any systemic agent.
Guideline: S2k guideline: diagnosis and treatment of chronic pruritus / chronic prurigo (Stander et al, JDDG 2022; PMID 36252071, DOI 10.1111/ddg.14830 — pursue + treat the underlying disease + symptomatic antipruritic ladder) + chronic prurigo incl. prurigo nodularis: new insights & treatments (Müller, Zeidler, Stander, Am J Clin Dermatol 2023; PMID 37717255, DOI 10.1007/s40257-023-00818-z) + dupilumab LIBERTY-PN PRIME/PRIME2 phase-3 RCTs (Yosipovitch et al, Nat Med 2023; PMID 37142763, DOI 10.1038/s41591-023-02320-9) + pooled (PMID 39006917, DOI 10.1016/j.jdin.2024.03.025) + atopic/non-atopic subgroup (Kim et al, Am J Clin Dermatol 2025; PMID 41219577, DOI 10.1007/s40257-025-00993-1) + nemolizumab OLYMPIA 2 (Kwatra et al, NEJM 2023; PMID 37888917, DOI 10.1056/NEJMoa2301333) + OLYMPIA 1 (JAMA Dermatol 2025; PMID 39602139, DOI 10.1001/jamadermatol.2024.4796) + OLYMPIA-LTE 100-wk (JEADV 2025; PMID 41405008, DOI 10.1111/jdv.70266) + gabapentinoid evidence (Gupta et al, Clin Dermatol 2018; PMID 30446200) + paroxetine RCT (Zylicz et al, J Pain Symptom Manage 2003; PMID 14654262) + PN QoL/economic burden (Whang/Kwatra, JAAD 2021; PMID 34058278)