PRURIGO NODULARIS¹

Prurigo nodularis (Hyde, Zeisler) —lichen obtusus corneous (Brocq,
C. J. White), tuberosis cutis pruriginosa (Hübner, Herxheimer)—is

¹Literature: Hardaway, Arch. Derm., 1880, p. 129; Corlett, “A Peculiar Disease
of the Skin, Accompanied by Extensive Warty Growths and Severe Itching,” Jour.
Cutan. Dis., 1896, p. 301 (with case illustration; male); Johnston, “A Papular, Persist­
ent Dermatosis,” Jour. Cutan. Dis., 1899, p. 49 (with case and histologic illustra­
tions); Brocq, La Pratique Dermatologique, 1902, vol. iii, pp. 201, 213, 216; Kreibich,
“Urticaria Perstans Verrucosa,” Archiv, 1899, vol. xlviii; Hartmann, “Ueber éine
urticariaartige Hauterkrankung,^,, Archiv, 1903, vol. 1xiv (severe cases, suggestively

PRURIGO NODULARIS                                 211

doubtless distinct from hypertrophic lichen planus, which in some of its
features it resembles. It is a rare malady, and was first described by
Hardaway (1880) under the descriptive title “multiple tumors of the skin
accompanied by intense itching,'’ and later by Brocq, Johnston, Kreibich,
Schamberg and Hirschler, Hübner and Herxheimer, Fasal, C. J. White,
Zeisler, and others. It is not improbable that some of the eases described
under the names “acne urticata,” “urticaria perstans,” “urticaria per-
stans verrucosa,” etc, represent the same malady. It is characterized
by more or less rounded, firm, often hard, elevated pinkish-white or
gray to brownish-red pea- to cherry-sized papules or nodules; scattered
over the legs, sometimes the arms, and occasionally elsewhere; they are
exceedingly itchy and persistent, and usually become covered with an
adherent scaly layer or stratified layers, which in some, owing to the

Fig. 39.—Prurigo nodularis (courtesy of Dr. Joseph Zeisler).

violent scratching often engendered, give place to an excoriated sur­
face and blood crust. Sometimes the lesions or some of them may be
quite warty in aspect and to the touch; and rarely there may be, as
in a case observed by me, in a few nodules, especially those on the
lowest part of the leg, a disposition to summit vesiculation. The lesions
are, as a rule, not numerous (thirty to fifty or more) and almost always

similar to this disease); Hübner (Herxheimer‘s Clinic), “Tuberosis Cutis Pruriginosa,”
Archiv, 1906, vol. lxxxi (one of the Hartmann cases); Schamherg and Hirschler, “Two
Cases of Multiple Tumors of the Skin in Negroes, Associated with Itching,” Jour.
Cutan. Dis., 1906, p. 151 (with case and histologic illustrations; patients both women);
C. J. White, “Lichen Obtusus Corneous—An Unusual Type of Lichenification,” Jour.
Cutan. Dis., 1907, p. 385 (with review of allied cases, case and histologic illustrations);
Hyde, “Treatise in Skin Diseases,” 8th edition, 1909, p. 174; Jackson, “Case of Mul­
tiple Tumors Associated with Itching,” Jour. Cutan. Dis., 1909, p. 39 (case demonstra­
tion; on right thigh only); Zeisler, “A Case of So-called Prurigo Nodularis,” Jour. Cutan.
Dis., Nov., 1912 (with case illustration; review of reported cases—similar and allied.
Zeisler, to whose papers I am indebted for some references, calls attention to suggestive
cases shown on Plate II, Ikonographia Dermatologica of 1906.

212                                 INFLAMMATIONS

remain discrete; exceptionally two or three or more crowding closely
together almost to the degree of actual coalescence, and forming a
small nodular patch; They are dull and sluggish looking, entirely
lacking the shiny and glazed appearance of lichen planus. When well
established they show little if any disposition to change, either toward
further development or to involution; and they may then remain for
years. Its course is persistently chronic; even when a lesion is cut
out, another is apt to come in its place. A few of the patients have alleged
that the first appearance of the eruption was as “blisters," or as wheals,
although medical observation of the cases later fails, excepting in White‘s
case, to corroborate this; however, constant rubbing or scratching may
produce on one or two lesions an attempt at vesicle or small thin bleb
formation, and, less frequently, by accidental infection, a pustular tend­
ency. While the eruption is generally somewhat disseminated, excep­
tionally it may be limited to a region, such as the thigh (Jackson‘s case); and
when close together the intervening and surrounding skin, doubtless from
the rubbing and scratching, may become rough and somewhat thickened.

The cause is not known. The cases, in this country at least, have,
excepting Corlett's case (?) all been women, mostly between the ages of
thirty and fifty, the malady may begin, however, as early as the age of
twelve, possibly earlier. The histopathology has been studied by the
various observers named, and have disclosed features of a papuloverru-
cous nature, with usually the horny layer markedly increased, and in­
flammatory changes of a perivascular character in the corium, less in the
papillary layer; and occasionally round, concentrically arranged nest-like
and column-like bodies in the corium, spreading about the blood-vessels.
Johnston found a tiny vesicle inclosed somewhat deeply in the central
apical portion. Johnston is of the opinion that the malady is to be
grouped with prurigo. C. J. White thought the histopathology of his
case approached rather closely that of lichen planus hypertrophicus,
though his patient exhibited some wheals.

Prognosis and Treatment.—All forms of treatment have been
tried in this rare disease, and the literature does not record a recovery.
For a while the medicated varnishes employed in psoriasis and the x-ray
seemed to be of some slight benefit. In Johnston's case there was some
improvement from full doses of arsenic, and in C. J. White's case from
the use of chrysarobin and lactic acid. In my case, under observation
for five or six months, all plans proved futile, the x-ray and chrysarobin
applications bringing some temporary betterment.¹

¹ Zeisler, who also used chrysarobin and it-rays, states “that the latter had a curious
effect—under their influence the hard keratomatous growths seemed to soften and
become transformed into vesicular lesions, which would gradually dry up. . . ."
I noted this change in some of the lesions in my case. The patient, in my case, was
a young woman of twenty-four, in whom the eruption had first appeared when a child
of about ten to twelve years of age; first in the lowest parts of the legs. At present
the eruption was quite abundant on both legs below the knees with a few lesions on
one thigh just above the knee, and some lesions had lately appeared on both arms;
some were closely grouped in threes and fours, but, as a rule, they were discrete; the
itching was intense, worse at night; while under observation a few of the lesions
under chrysarobin applications and x-ray seemed to soften, become vesicular—almost
bullous—dry up, and disappear. The patient stated that she had noted this change
occasionally before, I had first viewed this case as an unusual one of warty hyper-
trophic lichen planus.

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