Combined Methotrexate and Alitretinoin for the treatment of difficult-to-treat generalized prurigo nodularis: a case-series.

Prurigo nodularis is a chronic disabling skin disease with an adverse impact on quality of life1 . It is characterized by multiple intensely pruritic firm nodules, typically distributed symmetrically over the extensor surface of extremities. Treatment of PN is very challenging, involving treatments aimed at interrupting the itch-scratch cycle and flattening of the skin lesions. Despite the scarcity of strong data, a recent guideline and reviews have provided a treatment algorithm and summaries of evidence-based treatments with level of evidence ratings for each supporting study1-3 .