Understanding Prurigo Nodularis: The New Living Guideline
Prurigo nodularis is a chronic skin condition characterized by intensely itchy nodules that can significantly affect the quality of life. On July 6, 2026, the British Dermatological Society released a comprehensive living guideline that consolidates 27 expert recommendations for the management of this challenging condition. This article discusses these recommendations, providing insights for patients and healthcare providers alike.
General Management and Diagnosis
A multidisciplinary working group, led by George Millington from the Norfolk and Norwich University Hospitals NHS Foundation Trust, has crafted a guideline emphasizing comprehensive disease management. This includes thorough patient histories and clinical examinations, with attention to potential accompanying atopic dermatitis (AD). Utilizing scoring tools like the Dermatology Life Quality Index (DLQI) and the Prurigo Activity and Severity Score (PAS) can facilitate the assessment of the disease’s impact.
Patient education is paramount; individuals must be well-informed about their condition and treatment options. Educational materials such as brochures and website recommendations are crucial. Furthermore, understanding the “itch-scratch cycle” is vital in discussions with patients, as breaking this cycle is key to effective management. For basic skincare, using syndets and moisturizers is recommended.
Topical Therapy: The First Line of Treatment
Topical treatments are the frontline approach for managing prurigo nodularis. The guideline specifies several options:
Topical Corticosteroids or Tacrolimus: Patients with mild to severe prurigo nodularis should be offered treatment with topical corticosteroids or topical tacrolimus as a first-line option. In cases of more pronounced disease, these can also serve as adjunctive treatment. Patient preferences should be considered, and topical corticosteroids may be applied under occlusion depending on lesion extent.
Intra-lesional Steroid Injections: For localized or persistent lesions, intralesional corticosteroid injections may be appropriate.
Menthol Creams: Creams containing menthol (1%) can provide soothing relief.
In addition to topical therapies, non-sedating antihistamines, such as Fexofenadine, may be beneficial. However, antihistamines do not work for everyone. If sedating antihistamines (like Hydroxyzine or Chlorphenamine) are considered, they should be used at the lowest effective dosage for the shortest duration.
Phototherapy Options
Phototherapy can be an alternative when topical treatments fail to yield satisfactory results or are contraindicated. Narrowband UVB therapy, which has a better safety profile than Psoralen-UVA, may be suitable. For adolescents and adults with moderate to severe prurigo nodularis unresponsive to topical therapies or UVB treatment, a bath-Psoralen-UVA therapy can be considered. Cryotherapy is another option for localized or persistent prurigo nodularis and should be discussed with the patient, taking their preferences and treatment tolerance into account.
Systemic Therapy: The Role of Biologics
Moderate to severe cases often require systemic therapy. The guideline recommends:
Biologics: Adult patients with moderate to severe prurigo nodularis who are candidates for systemic therapy should be offered an approved biologic treatment, such as Dupilumab or Nemolizumab.
Oral Methotrexate or Cyclosporine: These can be considered for individuals who do not respond adequately to topical therapies or phototherapy or if these treatments are contraindicated.
Subcutaneous Methotrexate: This may be an option for patients who cannot tolerate oral administration or do not respond well to oral methotrexate.
Moreover, psychological support is crucial for patients experiencing a severe itch-scratch cycle. Cognitive behavioral therapy or habit-reversal training might be beneficial, and in some instances, psychiatric intervention and medication may become necessary. The guideline also stresses the importance of not overlooking suicide risk in this patient population.
Conclusion
The living guideline for managing prurigo nodularis introduces a structured approach to diagnosis and treatment. With evidence-based recommendations spanning topical therapies, phototherapy, and systemic interventions, including biologics, the healthcare community is better equipped to address this challenging condition effectively. Each patient’s experience with prurigo nodularis is unique, requiring a tailored approach that includes education, treatment options, and psychological support to improve quality of life.
For more detailed information, refer to the original study: Millington GWM et al., Br J Dermatol 2026; doi:10.1093/bjd/ljag070.
