Psychodermatological management of prurigo nodularis in an elderly patient: a case report

Introduction

Prurigo nodularis (PN) is a chronic inflammatory skin disorder characterized by intensely pruritic, hyperkeratotic nodules and a persistent itch–scratch cycle. Its pathophysiology involves complex interactions between cutaneous nerve fibers, immune responses and central sensitization processes (1). In elderly patients, PN is frequently associated with a substantial psychosocial burden, including sleep disturbance, social withdrawal and affective symptoms (3). Management in this population can be particularly challenging due to comorbid medical conditions that may limit therapeutic options. This case highlights the value of a multidisciplinary, integrated approach addressing both the biological and behavioral components of chronic pruritus (4).

Case

A 71-year-old female, a retired accountant, presented with a three-year history of severe generalized pruritus followed by the development of excoriated nodules. Her medical history included heart failure requiring pacemaker implantation, type 2 diabetes mellitus, hypertension, and stage 3 chronic kidney disease. A family history of similar dermatological lesions was reported in her father. Previous treatment with topical corticosteroids and antihistamines had provided minimal relief. Skin biopsies performed in 2022 and 2023 confirmed the diagnosis of PN and direct immunofluorescence excluded bullous pemphigoid.Dermatological examination revealed widespread erythematous and hyperpigmented nodules and plaques involving the extremities, back and scalp. A psychiatric consultation was requested due to persistent sleep disturbance and marked social withdrawal. The patient reported avoiding social interactions for over one year due to embarrassment related to her skin condition. Mental status examination revealed a mildly depressed affect and habitual, partially automatic scratching behavior, particularly during periods of inactivity in the evening. No psychotic symptoms or cognitive impairment were observed. Following multidisciplinary evaluation, the patient was initiated on narrowband ultraviolet B (NB-UVB) phototherapy and escitalopram. The medication was started at 5 mg/day and titrated to 10 mg/day. This approach was intended to address both affective symptoms and central processing of itch (2). Behavioral interventions, including the use of protective gloves and stress-reduction strategies, were also implemented. After eight weeks of combined treatment, the patient reported a marked reduction in pruritus intensity and improved social engagement. The treatment was well tolerated, with no observed adverse effects on cardiac or renal function.

Discussion

This case supports the importance of an integrated approach in the management of PN, where biological, behavioral, and psychological factors contribute to the persistence of chronic pruritus (4). Psychotropic treatment may provide benefit not only for associated mood symptoms but also for the modulation of itch perception, possibly via central serotonergic mechanisms (2). Combined therapeutic strategies may help interrupt the itch–scratch cycle and improve overall functioning (3). In elderly patients with complex medical comorbidities, careful selection and titration of pharmacological treatments are essential. This case suggests that low-dose selective serotonin reuptake inhibitors, when combined with phototherapy and behavioral interventions, may be a well-tolerated and effective option in selected patients.

Conclusion

An integrated psychodermatological approach may be beneficial in treatment-resistant PN, particularly in elderly patients with significant psychosocial burden. Combining dermatological therapies with targeted neuropsychopharmacological and behavioral interventions may enhance symptom control and quality of life.

References

Williams KA et al. J Am Acad Dermatol. 2020 Ständer S et al. Exp Dermatol. 2008 Ferreira BR et al. Dermatol Ther. 2024 Jafferany M. Prim Care Companion J Clin Psychiatry. 2007 American Psychiatric Association. DSM-5, 2013