CLINICAL HISTORY:

Signs and symptoms:  Patient: 38 year old black female. Patient presented to Dermatology Clinic with the chief •complaint of multiple lesions on skin. The lesions onset 23 years ago, at age 15. The symptom includes severe itching. The lesions were previously diagnosed as keloids.

Previous Treatment: 

Other information:  Current Medication: The past treatments include topical steroids and oral antihistamines

PHYSICAL EXAM:

Multiple elevated papular lesions with diameters ranging from 3-7mm distributed across bilateral arms. Hyperpigmentation are present on these lesions.

LABORATORY TESTS:

1. Deep shave biopsy of lesion from left forearm.

2. CBC - Within Normal Limits

3. Hepatic function panel - Within Normal Limits

4. HIV screen - Negative

5. Hepatitis Panel for A, B, C - Negative

DERMATOHISTOPATHOLOGY:

Microscopic Description: hyperkeratotic and acanthotic epidermis with papillomatosis and psoriasiform hyperplasia. Prominent basal pigmentation. Thickening of the subepithelial collagen. Dermal fibrosis. Capillary proliferation, slight chronic inflammation and scattered melanophages.

DIFFERENTIAL DIAGNOSIS:

1.   Keloids
2.   Prurigo Nodularis
3.   Dermatofibroma
4.   Sarcoidosis
5.  

SCROLL DOWN FOR ANSWER AND DISCUSSION.

CORRECT DIAGNOSIS:

Prurigo Nodularis

DISCUSSION:

Prurigo nodularis is a rare disease. It is considered as a nodular form of Lichen Simplex Chronicus. The true cause of prurigo nodularis is unknown. This diseases may present as few to as many as 200+ nodules randomly distributed on arms and legs, especially the extensor surface. The lesions are created by repeated scratching of the skin. They present usually as dome-shaped lesion of 1-2 cm in diameter.

Most patients with the disease are often middle-aged to elderly. Lesions may demonstrate excoriation with flat, umbilicated, or crusted tops. Other differential diagnosis to consider include xanthoma, insect bites, keratoacanthoma, molluscum contangiosum, and squamous cell carcinoma.

Skin biopsies may be indicated to exclude squamous cell carcinoma for these patients.

TREATMENT:

This patient was treated with oral antihistamine (Atarax) to break the itch-scratch cycle. In addition, patient received cryosurgery to the lesions with clinical improvements.

Some other possible treatment include the following:

Intralesional Steroid Injection - maybe beneficial for some patients.

Excision

REFERENCES:

1. Berger TG, Hoffman C, Thieberg MD: Prurigo nodularis and photosensitivity in AIDS: treatment with thalidomide. J Am Acad Dermatol 1995 Nov; 33(5 Pt 1): 837-8[Medline]

2. Meyers LN: Use of occlusive membrane in the treatment of prurigo nodularis [letter]. Int J Dermatol 1989 May; 28(4): 275-6

3. Perez GL, Peters MS, Reda AM: Mast cells, neutrophils, and eosinophils in prurigo nodularis. Arch Dermatol 1993 Jul; 129(7): 861-5

4. Stoll DM, Fields JP, King LE Jr: Treatment of prurigo nodularis: use of cryosurgery and intralesional steroids plus lidocaine. J Dermatol Surg Oncol 1983 Nov; 9(11): 922

5. Ferrandiz C, Carrascosa JM, Just M: Sequential combined therapy with thalidomide and narrow-band (TL01) UVB in the treatment of prurigo nodularis. Dermatology 1997; 195(4): 359-61

6. Waldinger TP, Wong RC, Taylor WB: Cryotherapy improves prurigo nodularis. Arch Dermatol 1984 Dec; 120(12): 1598-600

Additional Comment:

© Copyright 2003-2006 by AOCD Grand Rounds

Top of Page