How to treat prurigo nodularis in a pregnant 39-year-old?

Question

Hi doctor,

My 39-year-old daughter has prurigo nodularis that started during her last pregnancy two years ago and never went away. She has these thick, bumpy lesions all over her arms and legs that itch so intensely she scratches until they bleed. The dermatologist tried topical steroids, but they made her skin thin and did not provide much relief from the itching. She cannot sleep at night because the urge to scratch is unbearable, and her sheets are often stained with blood. tried antihistamines like Hydroxyzine, but they make her too drowsy to function during the day with her toddler. The worst part is that some of the prurigo nodularis lesions got infected from constant scratching, and she needed antibiotics.

Her paediatrician is worried about her breastfeeding while taking all these medications. The stress of dealing with chronic itching is making her postpartum depression worse. She wears long sleeves all the time to hide the scarred bumps and avoids social situations. Can hormonal changes from pregnancy cause prurigo nodularis to persist this long?

Thanks.

Answer 1

Hi,

Welcome to icliniq.com.

I understand your concern.

Prurigo nodularis that started in pregnancy and has persisted for two years later is not uncommon; pregnancy can trigger immune and skin sensitivity changes that sometimes reset the system and leave behind chronic itching disorders. Hormones themselves may have set it off, but now it is more of a self-perpetuating skin-nerve-itch cycle than just hormones. That is why topical steroids and antihistamines have not solved it.

Probable causes include pregnancy-triggered immune and hormonal changes leading to chronic prurigo nodularis.

Probable diagnosis:

Chronic prurigo nodularis post-pregnancy.

Investigations:

CBC (complete blood count), liver and kidney function (before stronger medicines).
Thyroid profile (thyroid disease sometimes linked with chronic itch).
Depression or anxiety screening, since mood and itch aggravate each other.

Differential diagnosis:

Atopic dermatitis with nodular lesions.
Chronic urticaria with excoriations.
Lichen simplex chronicus.

The constant itching, bleeding, infections, poor sleep, and the psychological toll are as important as the skin lesions themselves. Breastfeeding adds another layer since not all systemic options are safe during lactation. Still, there are safer routes — like certain non-sedating antihistamines, emollient therapy, light-based treatments (phototherapy), and in selected cases, immunomodulators (but those need specialist clearance with breastfeeding).

Preventive measures:

Keep nails short, wear gloves at night if scratching in sleep.
Avoid hot showers and harsh soaps.
Stick to cotton clothes to reduce irritation.
Stress management, since stress spikes itch perception.

Treatment plan:

She needs a combined dermatology and psychiatry approach since the itch–scratch–stress loop is strong.
Safer antihistamines (like Cetirizine or Loratadine) in daytime if required, Hydroxyzine reserved for night.
Thick emollients, menthol lotions, occlusive dressings to cut scratching damage.
Phototherapy can be considered and is usually safe in breastfeeding.
If depression is worsening, psychiatric input is important; some antidepressants also reduce itching.
Infected lesions should be treated promptly with short antibiotic courses.

She should follow up with a dermatologist regularly, but also loop in her gynaecologist and pediatrician to balance breastfeeding safety with needed medicines. Chronic itching like this does not just go away with time — it needs active management before scarring and depression worsen.

I hope this information will help you.

Thanks.