About: In recent decades, there’s been a growing amount of scientific literature on the associations between skin disease and psychological morbidities that affect patients’ overall mental health and well-being. In this series, we shine a spotlight on the mental health burdens and a few of the challenges unique to each skin condition.

Fast Facts About Prurigo Nodularis

• Prurigo nodularis (PN) is a chronic and debilitating skin disease characterized by disfiguring and itchy skin nodules covering extensive areas of the body that can often erode and bleed due to scratching.^1,2
• In addition to the persistent and intense itch, patients with PN can experience pain, burning, stinging, and alterations in lesion temperature that result in significant sleep disruption and contribute to a reduced quality of life.²
• While PN is a distinct disease, many patients with PN have significant associated comorbidities that present along with PN symptoms, including dermatologic, systemic, neurologic, and psychological conditions that can exacerbate the disease.^2-5
• Dermatologists frequently diagnose PN with a biopsy and clinical examination, but a complex disease pathology, underreported symptoms, and delays in diagnosis add to an already substantial burden on the patient.^3,6
• There is no cure for PN, and most treatments are focused on reducing itch and inflammation through different therapeutic mechanisms based on the patient’s response and comorbidities.^2,6,7

The Mental Health Burdens of Prurigo Nodularis

Patients with chronic PN endure significant unmet needs such as confusing diagnostic terminology, a poorly understood pathophysiology, and a lack of quality treatment options that pose frustrating barriers to managing their disease.^2,8 Those living with PN often report feelings of embarrassment over their appearance due to social stigmas, which results in avoiding personal or social interactions.^9,10 Poor health outcomes are compounded by psychological distress, resulting in high rates of anxiety and depression in patients with PN, which are found to be higher than with other skin diseases.^9-1

It has also been reported that patients with PN are more likely to experience suicidal ideation than people with other dermatologic conditions.¹⁰ While psychological comorbidities can be induced by PN, it is also likely that anxiety and depression can lead to pruritus and consequently trigger chronic prurigo, and researchers have postulated that PN is sometimes initially misdiagnosed as a psychiatric condition.^{3, 10} As a result of the many psychological burdens of the disease, many patients require clinical management for depression and other psychiatric conditions.^3,10,12

The severe and persistent itch associated with chronic PN is often the main culprit contributing to nocturnal pruritus and cycles of sleep disruption.^13,14 Clinical studies show that PN-related itch directly contributes to lower quality of life scores, sleep deprivation, and constant social isolation, making PN an oppressive disease that affects both physical and mental health of patients.^4,15

Addressing Mental Health Issues Related to Prurigo Nodularis   

Improving the burdens for patients with PN often requires an interprofessional team that should include a primary care physician or nurse practitioner, dermatologist, and mental health professionals.¹⁶

While many pharmacological treatments are intended to target the itch-scratch cycle and some of the systemic issues underlying the disease of PN, there are other nonpharmacological steps a patient can take that may enhance their mental health and their chances at a successful clinical outcome.¹⁶ Here are just a few suggestions that can help your patients:

1. Establish good physician-patient relationships that includes a team of psychiatrists, dermatologists, therapists, and social workers.^17,18
2. Create treatment goals to improve daily functioning and reduce sleep disturbances and physical distress.^17,18
3. Make a plan to manage psychiatric symptoms such as anxiety, depression, social withdrawal, and poor self-esteem.^17,18
4. Educate your patient and raise their awareness about the psychological challenges related to PN, and put them into contact with patient groups that can help improve their understanding of their disease.¹⁶

REFERENCES:

1.Huang AH, Williams KA, Kwatra SG. Prurigo nodularis: epidemiology and clinical features. J Am Acad Dermatol. 2020;83(6):1559-1565. doi:10.1016/j.jaad.2020.04.183

2.Kowalski EH, Kneiber D, Valdebran M, Patel U, Amber KT. Treatment-resistant prurigo nodularis: challenges and solutions. Clin Cosmet Investig Dermatol. 2019;12:163-172. doi:10.2147/CCID.S188070

3.Ständer S, Pereira MP, Berger T, et al. IFSI-guideline on chronic prurigo including prurigo nodularis. Itch. 2020;5(4):1-13. doi:10.1097/itx.0000000000000042

4.Aggarwal P, Choi J, Sutaria N, et al. Clinical characteristics and disease burden in prurigo nodularis. Clin Exp Dermatol. 2021;46(7):1277-1284. doi:10.1111/ced.14722 

5.Pereira MP, Steinke S, Bruland P, et al. Management of chronic pruritus: from the dermatological office to the specialized itch center: a review. Itch (Phila). 2017;2(2):e6. doi:10.1097/itx.0000000000000006

6.Kwatra SG. Prurigo nodularis. JAMA Dermatology. 2022;158(3):336. doi:10.1001/jamadermatol.2021.5307

7.Zeidler C, Pereira M, Ständer S. The neuromodulatory effect of antipruritic treatment of chronic prurigo. Dermatol Ther (Heidelb). 2019;9(4):613-622. doi:10.1007/s13555-019-00321-6

8.Pereira MP, Steinke S, Bruland P, et al. Management of chronic pruritus: from the dermatological office to the specialized itch center: a review. Itch (Phila). 2017;2(2):e6. doi:10.1097/itx.0000000000000006

9.Dazzi C, Erma D, Piccinno R, Veraldi S, Caccialanza M. Psychological factors involved in prurigo nodularis: a pilot study. J Dermatolog Treat. 2011;22(4):211-214. doi:10.3109

10.Brenaut E, Halvorsen JA, Dalgard FJ, et al. The self-assessed psychological comorbidities of prurigo in European patients: a multicentre study in 13 countries. J Eur Acad Dermatol Venereol. 2019;33(1):157-162. doi:10.1111/jdv.15145

11.Whang KA, Kang S, Kwatra SG. Inpatient burden of prurigo nodularis in the United States. Medicines (Basel). 2019;6(3):88. doi:10.3390/medicines6030088 (P.5, C.2, Ph.1, L.14-21)

12.Jørgensen KM, Egeberg A, Gislason GH, Skov L, Thyssen JP. Anxiety, depression and suicide in patients with prurigo nodularis. J Eur Acad Dermatol Venereol. 2017;31(2):e106-e107. doi:10.1111/jdv.13827

13.Kwatra SG. Breaking the itch-scratch cycle in prurigo nodularis. N Engl J Med. 2020;382(8):757-758. doi:10.1056/NEJMe191673 

14.Konda D, Chandrashekar L, Rajappa M, Kattimani S, Thappa DM, Ananthanarayanan PH. Serotonin and interleukin-6: association with pruritus severity, sleep quality and depression severity in prurigo nodularis. Asian J Psychiatr. 2015;17:24-28. doi:10.1016/j.ajp.2015.07.010

15.Ständer S, Ketz M, Kossack N, et al. Epidemiology of prurigo nodularis compared with psoriasis in Germany: a claims database analysis. Acta Derm Venereol. 2020;100(18):adv00309. doi:10.2340/00015555-3655

16.Mullins T, Sharma P, Riley C, Sonthalia S. Prurigo nodularis. StatPearls. Updated September 14, 2021. Accessed May 9, 2022. https://www.statpearls.com/ArticleLibrary/viewarticle/27913

17.Mohammad J. Psychodermatology: when the mind and skin interact. Psychiatric Times. December 9, 2011. Accessed May 9, 2022. https://www.psychiatrictimes.com/view/psychodermatology-when-mind-and-skin-interact

18.Pereira MP, Ständer S. Assessment of severity and burden of pruritus. Allergol Int. 2017;66(1):3-7. doi:10.1016/j.alit.2016.08.009