Advances in the Management of Prurigo Nodularis - Episode 4

Multidisciplinary Care for PN

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Raj Chovatiya, MD, PhD; Shawn Kwatra, MD; and Sarina B. Elmariah, MD, PhD, share the importance of having multiple health care providers across the disciplines when diagnosing and treating prurigo nodularis (PN).

Raj Chovatiya, MD, PhD: More broadly, from some of the comments that both of you made, there’s a lot going on in our patients’ lives. It’s often a multifactorial disease that needs multiple providers on that care team. Dr Kwatra, what does that care team look like for you, for someone who is struggling with prurigo nodularis [PN]? What kinds of health care providers might be involved in helping in this circumstance, aside from just you as a dermatologist?

Shawn Kwatra, MD: That’s a great question, Dr Chovatiya. When these patients come to us and they’ve been having an uncontrolled itch for so many years, it ravages all aspects of their life. So, No. 1, for me, is to get a sense of where they are mentally. A lot of providers think a psychological disorder is a predisposing factor for PN, but I contend that if you have PN, you have an unrelenting itch, and you’re going to have sleepless nights that then put you at a risk for having these psychological comorbidities. So, I try to screen patients for anxiety and depression and get them in with providers who can help them with those different comorbidities they may have without taking away from the fact that their disease is due to a very specific neuroimmune dysregulated state they’re in. I try to highlight that and say, “It’s not in your head, but we’re having you see another provider to make sure we can get you back to functioning as normally as you can be as quickly as possible.”

Type 2 diabetes is more common in patients with PN. You screen for that at baseline. I also think uncontrolled PN—we’ve done work showing that in the bloodstream, there are a lot of pathogenic mediators that may also be dysregulated in chronic kidney disease and type 2 diabetes. So, it’s more of a bidirectional relationship—if you’re not sleeping much, your blood glucose goes up, all that. We screen and get patients primary care physicians, and sometimes endocrinologists are also involved.

The big key to recognize is that this is a different patient population from atopic dermatitis or psoriasis. It’s older at disease onset, so it’s middle-aged to even above that time point. Patients are more likely going to have several disease comorbidities—hypertension, chronic obstructive pulmonary disease, many of these other conditions. To be honest, before the era of targeted therapies, it could be incredibly difficult to manage these patients, because agents like methotrexate or cyclosporine that we were using, we always have to worry about what specific comorbidities that patient has—hypertension, kidney disease, or any of those things. With targeted agents, we can give patients safe therapies. That’s a little bit about all the different care teams and providers who are involved.

Transcript edited for clarity