Considering Comorbidities When Treating Prurigo Nodularis in a 32-Year-Old Patient With Atopic Dermatitis and Asthma

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Case 2 involves a 32-year-old Caucasian man, a news reporter with longstanding atopic dermatitis from childhood who developed prurigo nodularis 6 months ago. His itch intensity rates 8 of 10 with sleep abnormalities, and he has nodules on upper arms and lower back. The patient also has asthma, representing the 30% of prurigo nodularis patients with atopic dermatitis history, a percentage even higher among African American patients. Current topical corticosteroids and calcineurin inhibitors no longer control his symptoms.

This case presents unique challenges due to the patient's active asthma. Nemolizumab studies in Japan reported asthma exacerbations, leading to exclusion of asthma patients from subsequent trials. Therefore, nemolizumab is contraindicated in patients with active asthma, making dupilumab the preferred first-line treatment. Topical treatments prove inadequate for extensive disease, and antihistamines like diphenhydramine are ineffective for prurigo nodularis since the condition involves different nerve pathways than histamine-mediated itch.

Dupilumab offers advantages for this patient by simultaneously treating prurigo nodularis, atopic dermatitis, and asthma through IL-4 and IL-13 pathway inhibition. Both dupilumab and nemolizumab are approved for atopic dermatitis, but dupilumab's broader indication profile and safety in asthma patients makes it ideal for complex cases. While nemolizumab may provide faster itch relief, dupilumab offers similar long-term efficacy with additional benefits for patients with multiple type 2 inflammatory conditions, emphasizing the importance of individualized treatment selection based on comorbidity profiles.