Dupilumab Most Effective Among Standard Drugs, Biologics in Prurigo Nodularis

Dupilumab therapy provides clinically meaningful improvements in prurigo nodularis compared to other options, new data suggest, supporting its use as the preferred first-line medication.1

These new findings resulted from a recent analysis authored by such investigators as András Bánvölgyi, MD, PhD, of Semmelweis University in Budapest, Hungary. Bánvölgyi and colleagues noted the debilitating itch-scratch cycle of prurigo nodularis, describing the condition as a chronic, intensely itchy skin disease characterized by hyperkeratotic nodules.

Additionally, they noted some of the biggest therapeutic challenges of prurigo nodularis result from the wide array of treatment modalities, from topical corticosteroids and calcineurin inhibitors to phototherapy.2

“Here, we aimed to conduct a systematic review and meta-analysis to evaluate the efficacy and safety of available therapies for PN, including both conventional and biologic therapies,” Bánvölgyi and coauthors highlighted.1

Study Design and Findings

Bánvölgyi et al carried out a comprehensive literature search in November 2023, implementing the Embase, PubMed, and CENTRAL databases for their analysis. They had 2 independent reviewers screen existing citations at both the title and abstract stage and during full-text review to determine their eligibility for inclusion. The team considered these studies if they enrolled individuals diagnosed with prurigo nodularis who had been on therapies specifically intended to manage this disease.

The investigators did not place limitations on geographic area or coexisting medical conditions, although studies limited solely to pediatric patients were not evaluated. Criteria for inclusion were structured according to the population–intervention–control–outcome framework, with adults with prurigo nodularis as the population, biologic drugs as the intervention, conventional therapies, placebo, or no therapies as comparators, and outcomes including itch severity improvement, reduction in any nodular lesions, shifts in quality-of-life, and findings related to safety.

The investigative team also looked into any observed safety findings, evaluating such data by the frequency of adverse event (AE) occurrences. They performed random-effects meta-analyses when data quantity and quality allowed for such assessments. From a total of 4914 records identified and screened, there were 128 studies which were shown to have met inclusion criteria for qualitative synthesis. Bánvölgyi and colleagues found 25 provided sufficient information to be incorporated into their meta-analyses.

In looking at studies on dupilumab’s use in prurigo nodularis, the drug’s use was linked to substantial reductions in severity of pruritus, with a mean difference of −5.76 (95% CI, −6.86 to −4.67). The investigators also noted significant improvements in study participants’ quality of life, as indicated by a mean difference of −11.84 (95% CI, −22.76 to −0.92). AEs were seen in 13% of individuals being treated with dupilumab (95% CI, 0.02–0.52). This, the team wrote, suggested an overall favorable safety profile.

Among the non-biologic options highlighted in their analysis, phototherapy produced complete responses in 23% of participants evaluated (95% CI, 9%–48%). Phototherapy also led to partial responses in 60% (95% CI, 39%–78%), and a complete non-response in 7% (95% CI, 1%–40%). Treatment via thalidomide resulted in complete response rates of 15% of participants (95% CI, 1%–71%). Bánvölgyi and coauthors also noted partial responses after using thalidomide in 49% (95% CI, 23%–75%) and a lack of response in 12% of cases (95% CI, 6%–23%).

Overall, the cumulative data in this analysis pointed to dupilumab as a medication leading to consistent and clinically meaningful benefits for those with prurigo nodularis. Bánvölgyi and colleagues also highlighted dupilumab’s comparatively reassuring safety profile. These data collectively support the drug’s role as a preferred first-line therapeutic. In contrast, phototherapy and thalidomide may be considered for select cases, as their use was associated with decreased rates of complete disease clearance and greater safety-related limitations.

From a research perspective, the investigative team’s findings highlight the necessity of further randomized clinical trials to better determine the efficacy of emerging therapies, especially newer biologics and Janus kinase (JAK) inhibitors. Bánvölgyi et al noted the value of direct comparative studies between biologics and JAK inhibitors for the purposes of examining any differences in efficacy and safety.

Further investigation into patterns of relapse, long-term medication durability, and standardized outcome measures was also described by the team as potentially helpful to help reduce heterogeneity across research and strengthen the base of evidence for management options.

“Dupilumab provides consistent, clinically meaningful improvements in PN with a favorable safety profile, supporting its use as the preferred first-line treatment option when available,” the investigators concluded.1 “Phototherapy and thalidomide remain alternatives for selected patients, but achieve complete clearance only in a few cases and have harbored significant safety concerns.”

References

1. Lancz A, Meznerics FA, Bánvölgyi A, et al. Efficacy and Safety of Conventional and Biologic Therapies in Prurigo Nodularis: A Systematic Review and Meta-Analysis. Int J Dermatol. 2026 Jan 6. doi: 10.1111/ijd.70246. Epub ahead of print. PMID: 41495913.

2. Müller S, Zeidler C, Ständer S. Chronic Prurigo Including Prurigo Nodularis: New Insights and Treatments. Am J Clin Dermatol. 2024 Jan;25(1):15-33. doi: 10.1007/s40257-023-00818-z. Epub 2023 Sep 17. PMID: 37717255; PMCID: PMC10796623.