Focusing on Treatment Adherence and Safety in a 68-Year-Old Patient With Prurigo Nodularis

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Case 3 features a 68-year-old Latino retired postal worker with recent-onset prurigo nodularis causing severe itch rated 8 of 10 with nodules on arms and upper back. His medical history includes stage 3 chronic kidney disease, hypertension, and well-controlled type 2 diabetes on semaglutide. The patient experiences sleep disruption and daily activity impairment, with his wife noting poor medication adherence and preference for simple treatment regimens.

Treatment selection in older patients with multiple comorbidities requires careful consideration of safety profiles and drug interactions. Traditional immunosuppressants pose risks in patients with chronic kidney disease, hypertension, and diabetes who typically take multiple medications. Targeted biologics like dupilumab and nemolizumab offer safer alternatives with minimal drug interactions. The patient's preference for less frequent dosing makes nemolizumab's monthly administration advantageous over dupilumab's biweekly schedule, supporting treatment adherence through shared decision-making.

Both biologics demonstrate excellent tolerability with minimal injection site reactions compared with older biologics. Safety discussions with patients should emphasize the targeted nature of these treatments and their superior safety profiles. Dupilumab has 9 years of market experience, while nemolizumab shows promising safety data. Dr Yosipovitch expresses comfort using these biologics even in patients with solid tumors, though caution is warranted in lymphoma patients. The current era represents a golden age for prurigo nodularis treatment, offering hope to previously desperate patients and potentially extending benefits to complex cases excluded from clinical trials.