Efficacy and Safety of Conventional and Biologic Therapies in Prurigo Nodularis: A Systematic Review and Meta-Analysis.

Prurigo nodularis (PN) is a chronic, intensely pruritic skin disorder characterized by hyperkeratotic nodules and a debilitating itch-scratch cycle. Conventional therapies have limited efficacy and safety issues, while biologics have recently emerged as a promising alternative. A systematic search of PubMed, Embase, and CENTRAL databases was conducted on November 20, 2023, to identify studies assessing treatments for PN. Primary outcomes were changes in pruritus and quality of life. Safety was evaluated by adverse event incidence. Random-effects meta-analyses were conducted when sufficient data were available. Of 4914 records screened, 128 studies met the inclusion criteria, of which 25 were included in the meta-analysis. In studies of dupilumab, treatment was associated with marked reductions in pruritus (mean difference [MD], -5.76; 95% confidence interval [CI], -6.86 to -4.67) and significant improvement in quality of life (MD, -11.84; 95% CI, -22.76 to -0.92), with adverse events reported in 13% of patients (95% CI, 0.02-0.52). Phototherapy achieved complete responses in 23% (95% CI, 9%-48%), partial responses in 60% (95% CI, 39%-78%), and no response in 7% (95% CI, 1%-40%). Thalidomide was associated with complete, partial, and no response rates of 15% (95% CI, 1%-71%), 49% (95% CI, 23%-75%), and 12% (95% CI, 6%-23%), respectively. Dupilumab offers consistent, clinically meaningful improvements in PN with a favorable safety profile, supporting its use as the preferred first-line treatment. Phototherapy and thalidomide remain alternatives for selected patients but achieve complete clearance in few cases and carry greater safety concerns.