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When A Patient Presents With A Three-Year History Of Severe Lower Extremity Itching
A 71-year-old female presented to the clinic for a diabetic foot examination. Initial examination revealed excoriations and superficial wounds to her anterior legs. She also had excoriations on her left arm. The patient claims that she could not stop scratching these areas and that it was worse throughout the night. The patient also presented exhibiting a very anxious demeanor. The patient had a previous diagnosis of edema but never had formal treatment for this condition, which she relates as present for about three years.
Her past medical history was significant for type 2 diabetes with neuropathy, hypertension, hypercholesterolemia, edema, osteoarthritis, and uterine cancer. Current medications included docusate sodium, polyethylene glycol 3350 (MiraLAX®,Bayer), insulin glargine (Lantus®, Sanofi Aventis), hydrochlorothiazide, insulin aspart (NovoLog®, Novo Nordisk), gabapentin, dulaglutide (Trulicity®, Lilly), lactulose, atorvastatin, glipizide, losartan potassium, aspirin (low-dose), metoprolol, vitamin D, and zinc. The patient’s surgical history included bilateral knee replacements, femur fracture fixation, hysterectomy, and an appendectomy. The patient has allergies to lisinopril and penicillin. Her mother and father are deceased, and both had type 2 diabetes. She was a non-smoker and did not consume alcohol or illicit substances. The review of systems was unremarkable. The patient had a body mass index of 44.62.
Physical exam revealed +1 pitting edema bilaterally with brawny venous stasis changes. As previously mentioned, excoriations were evident over the bilateral anterior legs (and left arm). The left anterior leg displayed a full-thickness wound measuring 2.0 cm in length x 1.8 cm in width x 0.2 cm in depth. The surrounding skin was erythematous and mildly lichenified with cicatrix. There was mild serous discharge but no signs of infection. The right anterior leg displayed excoriations with mild lichenification and cicatrix. The right leg appeared stable and uninfected as well. Pedal pulses were faintly palpable at one out of four. Capillary refill time was brisk to all digits. Protective sensation was intact at 10 out of 10 sites with a 10 gram monofilament. She exhibited diminished vibratory sensation at the level of the first MTPJ of both feet. The patient had a pes planus foot type bilaterally and gastrocnemius equinus, as demonstrated by the Silfverskiold test.
Key Questions To Consider
1. What conditions might you include in your
differential diagnosis?
2. What are the key points in the clinical presentation
that lead you to your diagnosis?
3. What characteristics or concomitant conditions might
one associate with this condition?
4. What are the typical treatment options available for
this condition?
Answering The Key Diagnostic Questions
1. Lichen simplex chronicus became the favored diagnosis in this case, but venous stasis dermatitis was also among the differential possibilities.
2. Compulsory itch/scratch cycle; subsequent thick, leathery changes to surrounding skin; location of itching; and paroxysmal presentation, especially at night.
3. Affects women more than men; rarely seen in children; associated with anxiety disorders or difficulty with social skills; more common with family history of atopy.
4. First-line treatments include corticosteroids, antihistamines, moisturizers, exfoliating products, capsaicin, and antibiotics for secondary infection.17 Urea may improve the efficacy of hydrocortisone for this condition.13 Other treatments include skin coverings, cold compresses, psychiatric medications and therapy when indicated, and calcineurin inhibitors.
Based on subjective and objective examination, we favored the diagnosis of neurodermatitis (lichen simplex chronicus) over venous stasis dermatitis. Initially, we chose to address the patient’s edema and the full thickness wound at the left anterior leg, which we lightly debrided under sterile conditions with a #15 blade. We then scrubbed the bilateral legs with Dakin’s solution, followed by povidone-iodine paint, and applied Unna boot compressive dressings. After stabilizing the wound and the edema, we prescribed a topical high-potency steroid (betamethasone dipropionate 0.05%) for seven days. We followed this treatment with a calcineurin inhibitor (tacrolimus ointment) for an additional 14 days. On the last visit, we noted good resolution of the patient’s concerns.
What You Should Know About Neurodermatitis (Lichen Simplex Chronicus)
Neurodermatitis, also known as lichen simplex chronicus (LSC), is a dermatologic condition that manifests as compulsory itching of the skin. The exact etiology and pathophysiology are not fully understood; however, there appears to be a positive feedback loop of pruritus leading to scratching and subsequent nerve irritation within the skin.1-5 This skin irritation leads to pruritus, and the cycle repeats. The urge to scratch can become chronic and so severe that the skin undergoes clinical changes, becoming thick, leathery, and forming plaques over the irritated areas. Frequent triggers include physical irritation of the skin, environmental factors like heat and continued dampness, as well as psychological factors, such as stress. The most commonly affected regions are the extremities, anogenital region, and the back of the neck or scalp.1-5 The itching may also be paroxysmal and most notable during moments of relaxation or sleep. In some cases, the patient even wakes up scratching or rubbing the affected area.6 These clinical signs, accompanied by a thorough history, can help key evaluating providers into a diagnosis of neurodermatitis.
Neurodermatitis itself remains elusive because it is a relatively common skin condition, affecting up to 12 percent of the population, yet we still have a poor understanding of why it occurs.5 Even though there is no clear explanation of the disease process, it does have several cohort associations and often manifests in people with certain psychological characteristics. It affects women more often than men; usually in adults - particularly those between 30 to 50 years old - and is rarely seen in children. It is also associated with people with ligamentous laxity, have poor social skills, and those with anxiety disorders.8-10 Furthermore, patients with a family history of atopy seem to be more susceptible to developing neurodermatitis.9,10
Although neurodermatitis is not life-threatening and is not contagious; it can produce a serious psychosocial burden on patients and those around them.6 An analysis of the quality of life experienced by those suffering from this condition considered it moderately debilitating.5 The repetitive cycle can even negatively affect a patient’s sexual health.7 With this in mind, we must find ways to help alleviate our patients’ symptoms and treat the lichenification. Typical first-line treatments include:
• corticosteroids;
• antihistamines;
• moisturizers;
• exfoliating products;
• capsaicin; and
• even antibiotics when infection arises secondary to scratching of the skin.17
Adding urea may result in improvement in the therapeutic efficacy of hydrocortisone.13 One often uses these treatments in conjunction with skin coverings (dressings, bandages, or sleeves), cold compresses, and psychiatric treatment (antidepressants combined with behavior modification and therapy). Further medications and modalities are often necessary for continued treatment of neurodermatitis, which include calcineurin inhibitors (tacrolimus ointment and pimecrolimus),12-14,18,19 topical aspirin,12 botulinum toxin, phototherapy, and even surgery.
A Closer Look At A Targeted Treatment Option
It is the senior author’s opinion that calcineurin inhibitors are an important part of the treatment algorithm for neurodermatitis and lichen simplex chronicus and, in particular, refractory neurodermatitis. Calcineurin inhibitors work by suppressing the immune system by blocking T-cell proliferation, specifically by inhibiting its key signaling phosphatase calcineurin and its effects on interleukin-2.19 The two most common calcineurin inhibitors used for dermatologic purposes are tacrolimus ointment and pimecrolimus. Tacrolimus ointment has proven more effective, with a similar safety profile, compared with pimecrolimus cream in patients with atopic dermatitis previously treated with topical corticosteroids.13 Initial treatment with a topical steroid followed by a course of a topical calcineurin inhibitor has yielded great results for the senior author, as demonstrated with this case.
A diagnosis of neurodermatitis can be a difficult one to approach for both the patient and the practitioner, as it often involves treatment with a combination of medications and modalities, including addressing any psychiatric and triggering stimuli with behavior modifications. Even while utilizing best practices, managing neurodermatitis can be a continual and challenging battle due to the chronic nature of the condition.
In Conclusion
The underlying catalyst in lichen simplex chronicus does seem to have a psychological basis in most cases. In our patient’s case, this was most likely undiagnosed anxiety, evident on subjective evaluation. Curing the acute presentation of lichen simplex chronicus is fairly straightforward, but addressing the underlying etiology can be a bit challenging. In hindsight, a referral to behavioral medicine would have been beneficial to the patient. As a podiatric dermatology Fellow in Northeastern Pennsylvania, presenting cases of lichen simplex chronicus were fairly common, but I have not seen many cases in my career since. At first glance, one could easily diagnose this case as venous stasis dermatitis, due to the presence of edema and venous stasis-like changes. The excoriations on her arm and the obvious, anxious personality trait aided in making the correct diagnosis.
Dr. Stas is fellowship-trained in podiatric dermatology and is an Associate of the American College of Foot and Ankle Surgeons. He practices with NOMS Foot and Ankle Care Center of Youngstown, OH.
Dr. Rizkalla is a third-year podiatric resident at East Liverpool City Hospital in East Liverpool, OH.
1. Lotti T, Buggiani G, Prignano F. Prurigo nodularis and lichen simplex chronicus. Dermatol Ther. 2008;21(1):42–46. doi: 10.1111/j.1529-8019.2008.00168.x.
2. Vaalasti A, Suomalainen H, Rechardt L. Calcitonin gene‐related peptide immunoreactivity in prurigo nodularis: a comparative study with neurodermatitis circumscripta. Br J Dermatol. 1989;120(5):619-623. doi: 10.1111/j.1365-2133.1989.tb01346.x.
3. Prajapati V, Barankin B. Answer: Answer to Dermacase. Can Fam Phys. 2008;54(10):1392–1393.
4. Ludmann P. Eczema types: neurodermatitis overview. American Academy of Dermatology website. Available at: https://www.aad.org/public/diseases/eczema/neurodermatitis . Updated January 20, 2021. Accessed January 6, 2022.
5. An JG, Liu YT, Xiao SX, Wang JM, Geng SM, Dong YY. Quality of life of patients with neurodermatitis. Int J Med Sci. 2013;10(5):593–598. https://doi.org/10.7150/ijms.5624.
6. Koca R, Altin R, Konuk N, Altinyazar HC, Kart L. Sleep disturbance in patients with lichen simplex chronicus and its relationship to nocturnal scratching: a case control study. South Med J. 2006;99(5):482–485. doi: 10.1097/01.smj.0000215640.97668.3f.
7. Ermertcan AT, Gencoglan G, Temeltas G, Horasan GD, Deveci A, Ozturk F. Sexual dysfunction in female patients with neurodermatitis. J Androl. 2011;32(2):165-169. doi: 10.2164/jandrol.110.010959.
8. Konuk N, Koca R, Atik L, Muhtar S, Atasoy N, Bostanci B. Psychopathology, depression and dissociative experiences in patients with lichen simplex chronicus. Gen Hosp Psychiatry. 2007;29(3):232–235. doi: 10.1016/j.genhosppsych.2007.01.006.
9. Liao YH, Lin CC, Tsai PP, Shen WC, Sung FC, Kao CH. Increased risk of lichen simplex chronicus in people with anxiety disorder: A nationwide population-based retrospective cohort study. Br J Dermatol. 2014;170(4):890-894. doi: 10.1111/bjd.12811.
10. Bhatia MS, Gautam RK, Bedi GK. Psychiatric profile of patients with neurodermatitis. J Indian Med Assoc. 1996;94(12):445-446.
11. Yosipovitch G, Sugeng MW, Chan YH, Goon A, Ngim S, Goh CL. The effect of topically applied aspirin on localized circumscribed neurodermatitis. J Am Acad Dermatol. 2001;45(6):910-913. doi: 10.1067/mjd.2001.117399.
12. Kirsner RS, Heffernan MP, Antaya R. Safety and efficacy of tacrolimus ointment versus pimecrolimus cream in the treatment of patients with atopic dermatitis previously treated with corticosteroids. Acta Dermatol Venereol. 2010;90(1):58–64. https://doi.org/10.2340/00015555-0748.
13. Bao Y, Wen SU, Yu FU. Clinical efficacy of 0.1% tacrolimus ointment combined with paroxetine for the treatment of neurodermatitis. Chinese J Dermatol. 2001;45(5):333-336.
14. Tan E, Tan A, Tey HL. Tacrolimus ointment 0.1% in the treatment of scrotal lichen simplex chronicus: An open-label study. J Am Acad Dermatol. 2013;68(4 suppl 1):AB38.
15. Wohlrab W. Introduction neurodermatitis and urea. [Article in German] Hautarzt. 1992;43(Suppl 11):1–4.
16. Huang HQ, Lai W, Zhu GX. Multiple center clinical trial of fluticasone propionate ointment in the treatment for localized eczema and neurodermatitis. Chinese J Dermatovenereol. 2005;11:672-673,681.
17. Tan ST, Firmansyah Y, Pratiwi YI. Treatment for neurodermatitis - based on pathogenesis of it (Retrospective Study). J Holistic Trad Med. 2021;6(01):548-554.
18. Safarini OA, Patel J. Calcineurin inhibitors. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021. https://www.ncbi.nlm.nih.gov/books/NBK558995/.
19. Buckley D. Topical immunomodulators (TIMs). In: Buckley D, Pasquali P (eds).Textbook of Primary Care Dermatology. Springer;2021:575-578.
