Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
Images in Dermatology
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Media and news
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Images
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Snippets
Special Article
Specialty Interface
Studies
Study Letter
Study Letters
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Tables
Technology
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
Therapy Letters
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF

Translate this page into:

Net Letter
2016:82:2;239-239
doi: 10.4103/0378-6323.174413
PMID: 26924412

Treatment of prurigo nodularis with dexamethasone-cyclophosphamide pulse therapy

Ramji Gupta
 Department of Dermatology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India

Correspondence Address:
Ramji Gupta
47-C Pocket B Siddhartha, Extension New Delhi - 110 014
India
How to cite this article:
Gupta R. Treatment of prurigo nodularis with dexamethasone-cyclophosphamide pulse therapy. Indian J Dermatol Venereol Leprol 2016;82:239
Copyright: (C)2016 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Prurigo nodularis is a chronic, intensely pruritic nodular condition usually found on the lower extremities, though it can occur anywhere on the body. It was first described by Hardway in 1880 and named by Hyde and Montgomery in 1909. [1] The aetiology of the disease is still not clear. Three types have been described: (i) atopic (ii) non-atopic and (iii) human immunodeficiency virus (HIV) associated. [2] Treatment modalities that have been tried with limited success include antihistamines, topical and intralesional corticosteroids, calcipotriol, capsaicin, thalidomide, lenalidomide, cyclosporine, narrow-band UVB, cryotherapy, pulsed dye laser and recently pregabalin and roxithromycin with tranilast.

Dexamethasone-cyclophosphamide pulse (DCP) therapy has been widely used to treat a large number of autoimmune diseases such as pemphigus, [3] systemic sclerosis [4] and systemic lupus erythematosus [5] with prolonged or permanent remission in several patients. Therapy is administered as 100 mg of dexamethasone dissolved in 500 mL of 5% dextrose, infused over 1-1.5 hours on three consecutive days to which cyclophosphamide 500 mg is added on day 2. These intravenous "pulses" are repeated every 28 days, while oral cyclophosphamide is given daily in a dose of 50 mg. The whole regimen is divided into four phases. [5] Phase I is continued until all lesions clear. In phase II, nine more pulses are given. In phase III, only oral cyclophosphamide is given for 9 months. In phase IV, patients are followed up for any recurrence.

We report three cases of prurigo nodularis unresponsive to various therapies which subsequently responded to Dexamethasone-cyclophosphamide pulse (DCP) therapy. All had itching of unknown aetiology before developing prurigo with no history of atopic dermatitis.

Case 1 was a 41-year-old female with itchy nodules on both legs [Figure - 1] and lower back since 15 years. Histopathology was consistent with prurigo nodularis [Figure - 2]a and b. Prior intermittent treatment with dapsone, methotrexate, levocetrizine, betamethasone and flucinolone acetonide for 3 years gave mild, transient improvement. Itching disappeared within 15 days after the first Dexamethasone-cyclophosphamide pulse (DCP) pulse and following the second pulse all lesions cleared, leaving behind depigmentation [Figure - 3], Subsequently, the patient was administered seven more pulses while remaining asymptomatic. Afterwards, a biopsy showed no signs of prurigo nodularis [Figure - 4]. There was no recurrence in a year of follow-up after the last pulse.

Figure 1: Prurigo nodularis, leg before treatment
Figure 2: (a) Prurigo nodularis before treatment (H and E, ×10), (b) Nerve hypertrophy (H and E, ×100)
Figure 3: Prurigo nodularis, leg after treatment
Figure 4: Prurigo nodularis, after treatment (H and E, ×10)

Case 2 was a 71-year-old male with itchy papules all over the body for 2 months. Histopathology supported the diagnosis of prurigo nodularis. There was no improvement after treatment for a month with prednisolone, dapsone, cyproheptadine hydrochloride and topical urea 10%. Dexamethasone-cyclophosphamide pulse (DCP) therapy was started and itching disappeared after the second pulse and lesions after the third pulse. A skin biopsy after the third pulse showed no evidence of prurigo nodularis and the patient discontinued the therapy on his own. However, he developed clinical and histopathological recurrence after 3 months. Pulse therapy was restarted with reduced pruritus and complete clearance of papules following six pulses. Subsequently, he was given seven more pulses and there was no recurrence during 2 years of follow-up.

Case 3 was a 51-year-old male with itchy papules on his legs, arms and abdomen for 1 year. The biopsy findings were consistent with prurigo nodularis. Betamethasone tablets and clobetasol cream were prescribed for a month with no response. Dexamethasone-cyclophosphamide pulse (DCP) pulse therapy was started, with complete clearance of lesions after the third pulse. However, the patient subsequently discontinued the therapy. After 3 months, the condition relapsed and the patient was lost to follow-up.

Many modalities of therapy have been claimed to be effective in clearing lesions of prurigo nodularis but frequently, relapse occurs after discontinuation. With Dexamethasone-cyclophosphamide pulse (DCP) therapy in prurigo nodularis, unlike the classical four-phase regime as given in pemphigus and other autoimmune disorders, response was seen with the initial two to three pulses itself but required seven more pulses to prevent relapse. We infer that Dexamethasone-cyclophosphamide pulse (DCP) therapy could be a valuable therapeutic alternative in cases of prurigo nodularis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References
1.
Hyde JN, Montgomery F H A. Practical treatise on diseases of the skin for the use of students and practitioners. Philadelphia: Lea and Febiger; 1909 p. 174-5.
[Google Scholar]
2.
Tanaka M, Aiba S, Matsumura N, Aoyama H, Tagami H. Prurigo nodularis consists of two distinct forms: Early-onset atopic and late-on-set nonatopic. Dermatology 1995;190:269-76.
[Google Scholar]
3.
Pasricha J S, Dass S S. Curative effect of dexamethasone -cyclophosphamide pulse therapy for the treatment of pemphigus vulgaris. Int J Dermatol 1992;31:875-7.
[Google Scholar]
4.
Gupta R. Systemic sclerosis treated with dexamethasone pulse. Indian J Dermatol Venereol, Leprol 2003;69:191-2.
[Google Scholar]
5.
Gupta R, Gupta S, Khera V. Dexamethasone cyclophosphamide pulse therapy in systemic lupus erythematosus: A case report. J Dermatol Treat 2009;20:55-8.
[Google Scholar]

Fulltext Views
5,094

PDF downloads
1,269
Show Sections