A 68-year-old patient had suffered from prurigo nodularis for 7 months. No significant improvement was seen after 3 months of oral antihistamine drugs such as cetirizine hydrochloride tablets (1 tablet Qd), ketotifen fumarate tablets (1 tablet Qd) and topical hormonal creams such as cream d. ‘halometasone (bid), desonide cream (bid) in local hospitals. The patient has not had a history of atopic dermatitis and benign prostate tumors for 3 years. Physical examination revealed extensive hyperkeratosis nodules and excoriations on the scalp, extensor side of extremities, and trunk (Figure 1).
Figure 1 W0 (lesions of prurigo nodularis at inclusion).
The Numerical Rating Scale (NRS) for itching expresses 9 points (0 means no pruritus, 10 means worse pruritus), patients say the itching is uncontrollable and frightening. The NRS for sleep gets 5 points (0 to 10 points, higher scores mean poorer quality of sleep), the Hospital Anxiety and Depression Scale (HADS) gets 14 points (HADS- A scores 8 points, and there was a clear tendency towards anxiety), the Dermatology Life Quality Index (DLQI) scores 9 points and the Investigator’s Global Assessment Scale (IGA) scores 4 points. The blood level of IgE is 365 IU / mL (normal range
Selection of acupuncture points: Baihui (GV20), Shenting (DU24), Fengfu (DU16), Daizhui (DU14), Zhongwan (CV12), Qihai (RN6), Bilateral Fengchi (GB20), Geshu (BL17), Tianshu ( ST25), Xuehai (SP10), Zusanli (ST36), Sanyinjiao (SP6), Xuqu (GB40), Chongyang (ST42), Jinggu (BL64), Quchi (LI11), Waiguan (SJ5), Hegu (LI4), Yangchi ( SJ4), Wangu (SI4).
Handling: Routine sterilization, a disposable sterile thread-like needle, 0.25 × 40 mm was selected. For GV20, DU24, insert the needles perpendicular and passing under the epicranial fascia, then change the angle to 15 ° against the scalp, 20-30mm deep. At DU16, GB20, pierce the needle 20-30mm towards the mandible. At DU14, BL17, insert the needles obliquely at an angle of 15 °, 20-30 mm deep. Keep the needles in place and have the patient lie on their back, at CV12, ST25, RN6, LI11, SJ5, LI4, SJ4, SI4, SP10, ST36, SP6, GB40, ST42, BL64, needles are inserted perpendicular, 25– 35 mm deep. All needles are kept for 30 min. The treatment was administered three times a week.
During the second week of acupuncture treatment, the itchy NRS scored 7 points. There were few new rashes. After 4 weeks of treatment, the NRS itch scored 4 points. The skin damage has been greatly improved and some small nodules have been flattened. No new rash (Figure 2). The NRS for sleep scored 8 points. By week 8, due to overwork in decorating the house, the NRS itch score was 6. No new rash; by the 10th week, the majority of the nodules are flattened, except for dozens of larger ones. The NRS for itching scored 2 points, indicating that there is basically no itching during the day and slight itching at night before bed, which could be controlled without scratching (Figure 3). At week 13, the NRS itch scored 2 points and had fewer rashes. By week 16 all but a small number of nodules on both upper limbs had disappeared with pigmentation on the left (Figure 4). The itch NRS scored 1 point, the NRS for sleep scored 9 points, the HADS scored 2 points, the DLQI scored 5 points, and the IGA scored 3 points. The blood level of IgE is 41 IU / mL (normal range
Figure 2 W4 (prurigo nodularis improved after acupuncture treatment at week 4).
figure 3 W10 (prurigo nodularis improved after acupuncture treatment at week 10).
Figure 4 W16 (prurigo nodularis improved after acupuncture treatment at week 16).
Figure 5 F1 (followed for 1 month).
Figure 6 F2 (follow-up for 2 months).
Prurigo nodularis is an intractable itching skin disease that is likely to occur on the extensor aspect. The cause of the disease is not yet clear. Compared with other skin conditions such as atopic dermatitis and psoriasis, PN is more likely to be associated with depression or anxiety.1 Conventional treatment of oral antihistamines, immunosuppressants, etc., has varying degrees of side effects. Biologics such as Dupilumab and Nemolizumab have been shown to be effective,2.3 but new drugs have drawbacks such as high price and long service cycle. The external treatment of traditional Chinese medicine such as the fire needle has been proven to have a certain effect,4 but the operation is complicated for patients with more rashes. Chinese acupuncture, with its characteristics of regulating Yin and Yang, dredging channels and collaterals, calming nerves and thoughts, strengthening Qi and resisting evil, can thus help patients with lumpy pruritus. to improve the quality of sleep, regulate bad emotions, then promote the regression of rash, so that forms a benign cycle. Traditional Chinese Medicine recognizes: “All pain is excess; all itching is a deficiency. The excess, the evil qi is real; deficiency, righteous qi is weak… the one that itches often, righteous qi is also weak. This suggests that acupuncture treatment should take vital Qi as the first. GV20, DU24 and DU16 can calm the nerves and promote the brain to play a leading role, which is the key point to enhance the emotions. CV12, ST25, RN6, and ST36 regulate spleen and stomach function and protect righteous qi (spleen and stomach qi is also called righteous qi). DU14, GB20, LI11, SJ5, BL17, SP10, SP6 can disperse wind, cool blood, activate blood and stop itching. Prurigo nodularis is likely to occur on the extensor aspect of the body, which in TCM theory is also part of the skin of the six Yang meridians of the hands and feet. GB40, ST42, BL64, LI4, SJ4 and SI4 are the original acupuncture points of the Six Yang Meridians of the hands and feet, which can stimulate the flow of energy from these Yang meridians. It has been proven that acupuncture plays a role in regulating the nerves, immunity, endocrine system. Some studies have shown that acupuncture can activate C fibers to consume neurotransmitters, inhibit mast cells to release a variety of itch mediators, etc. to play an antipruritic effect.5
Treatment with acupuncture can quickly relieve the degree of itching, control new rashes, and improve patients’ anxiety and depression, as well as quality of sleep and quality of life. The results of the follow-up show that the curative effect of acupuncture is long-lasting and stable. From this case, we can say that acupuncture therapy can greatly improve all aspects of the discomfort in patients with prurigo nodularis. It has the advantages of a single therapy with multiple effects, no side effects and low economic burden.
This study was approved by the Ethics Committee of Shanghai Yueyang Hospital for Integrated Traditional Chinese and Western Medicine and was in accordance with the 1964 Helsinki Declaration and its subsequent amendments or comparable ethical standards. Written informed consent to participate was obtained from all individual participants included in the study.
The authors report no conflicts of interest in this work.
1. Huang AH, Williams KA, Kwatra SG. Prurigo nodularis: epidemiology and clinical features. J Am Acad Dermatol. 2020; 83 (6): 1559-1565. doi: 10.1016 / j.jaad.2020.04.183
2. Chiricozzi A, Maurelli M, Gori N, et al. Dupilumab improves clinical manifestations, symptoms and quality of life in adult patients with chronic lumpy prurigo. J Am Acad Dermatol. 2020; 83 (1): 39-45. doi: 10.1016 / j.jaad.2020.03.049
3. Ständer S, Yosipovitch G, Legat FJ, et al. Trial of nemolizumab in moderate to severe lumpy prurigo. N English J Med. 2020; 382 (8): 706-716. doi: 10.1056 / NEJMoa1908316
4. Luo Y, Kuai L, Song N, et al. Efficacy and safety of fiery needle therapy for lumpy prurigo: a quantitative study. Evid Based Complement Alternat Med. 2019; 2019: 8797056. doi: 10.1155 / 2019/8797056
5. Haomiao B, Yan L, Liuliu Z, et al. Itching regulation mechanism. J Neuroanat. 2020; 36 (06): 679-684.