Localised dermatitic nodules but no itch.

Dear Editor, In 1909, Hyde fi rst described nodular prurigo as pruritic nodules on the extensor surfaces of the lower extremities in middle-aged women. Thus, nodular prurigo is also known as Hyde's prurigo. As the name suggests, nodular prurigo is a chronic dermatosis characterised by an intensely pruritic, papulonodular eruption. We describe a patient who presented with nodular prurigo in a unilateral lower limb due to dysaesthesia and sciatica pain instead of itch. A 53-year-old man with no known medical or dermatological problem presented to us with multiple lumps on the right lower limb. On examination, he had multiple excoriated nodules only on the right shin extending up to the thigh in the L5 dermatome suggestive of nodular prurigo (Fig.1). There was no itch but instead he complained of dysaesthesia and admitted to constant rubbing and peeling of the skin in order to get rid of the uncomfortable sensation. On further questioning, he revealed that he had been experiencing shooting pains from the buttock down to his right leg whenever he stretched his back for the last 1 year. Neurological examination of the legs revealed normal refl exes, sensation and motor function. Routine blood tests including full blood count, renal function and liver function tests were normal. Biopsy of one of the nodules showed fi ndings consistent with nodular prurigo. There was psoriasiform hyperplasia, irregular acanthosis with focal hypergranulosis (Fig. 2A). The superfi cial and deep vascular plexuses showed lymphocytic and plasmacytic cuffi ng. In addition, there was evidence of neural hyperplasia, with the clear identifi cation of nerve trunks adjacent to the lympho-plasmacytic cuffi ng (Fig. 2B). Magnetic resonance imaging of the lumbosacral spine revealed degenerative disc disease affecting the lower lumbar region, worse at L4/5 (Fig. 2C). The right exiting L5 nerve root was compressed (Fig. 2D). To our knowledge, this is the second case of a rare occurrence of nodular prurigo in an area of pain instead of itch. Batta et al 1 fi rst described a case of nodular prurigo occurring in the same distribution as sciatic pain from a prolapsed intervertebral disc. We would like to highlight that itch may not be an essential triggering factor that leads to the formation of nodular prurigo, and that dysaesthesia and pain from radiculopathy resulting in rubbing and peeling may also lead to nodular prurigo. Even though our patient did not experience any itch in the dermatome of …