Prurigo nodularis after acupuncture

CASE A 52-year-old man without a history of atopy was referred to the dermatology clinic at the City of Hope Medical Center for lesions on his arms and legs that had been present for several months. He stated that they began to appear days after receiving traditional needle acupuncture therapy. The location of the lesions on his extremities coincided with where the acupuncture needles had been placed. The patient’s medical history included papillary thyroid cancer, thyroidectomy, subsequent hypothyroidism (treated with levothyroxine and euthyroid at the time of presentation based on a normal thyroidstimulating hormone level), hyperlipidemia, and prostatic hypertrophy. Given his history of cancer, the patient was concerned that his skin lesions represented cancer recurrence. Skin lesions were extremely pruritic and continued to increase in size after acupuncture. Examination found five 15-mm hyperkeratotic papules and plaques located on the bilateral upper and lower extremities (Fig 1). Skin of the chest, back, face, scalp, and abdomen were unaffected. A shave biopsy performed on plaques of the right dorsal arm and left forearm found PN. The left forearm lesion additionally had ulceration and secondary bacterial colonization. A left forearm skin culture found methicillin-sensitive Staphylococcus aureus; this was thought to represent colonization