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Prurigo Nodular Prurigo Nodularis 446 / Arch Argent Pediatr 2008;106(5):443-457 / Comunicaciones breves Comunicaciones breves Prurigo nodular Prurigo nodularis Dra. Liz Lezcano*, Dra. Beatriz Di Martino Ortiz*, Dra. Mirtha Rodríguez Masi*, Dra. Oilda Knopfelmacher* y Dra. Lourdes Bolla de Lezcano* RESUMEN Según algunos autores, las lesiones pueden Los prurigos constituyen un grupo heterogéneo de trastornos, presentarse como nódulos duros, redondeados e de etiología dudosa o desconocida, caracterizados por prurito acentuado, como síntoma subjetivo principal, y una erupción hiperqueratósicos y con superficie deprimida. crónica o recurrente de tipo papulonodular, como síntoma Son también un hallazgo frecuente las placas objetivo. Se dividen en agudos y crónicos, y las formas agudas liquenoides.1 son las más frecuentes en la infancia. La piel entre las lesiones ha sido descrita como Presentamos el caso de un niño con prurigo nodular, la varie- dad crónica de los prurigos, de aparición bilateral y simétrica normal, así como también xerótica o liquenificada en ambas regiones axilares. en otros casos.2 Palabra claves: prurigo, prurito, prurigo nodular, prurigo crónico. Su etiología es desconocida, pero se piensa en factores emocionales, atópicos y en un factor indi- SUMMARY 3 Prurigos are a heterogeneous group of disorders of question- vidual de hipersensibilización. able or unknown etiology characterized by subjective symp- toms such as accentuated itching and an eruption of chronic or recurrent papulonodules as an objective sign. They are CASO CLÍNICO divided into acute and chronic; acute forms being the most frequent in childhood. Paciente lactante de sexo masculino de 1 año y We present the case of a child with nodularis prurigo, a variety 7 meses. Consulta a nuestro servicio de dermatolo- of chronic prurigo, with symmetrically affected axilary re- gía por nódulos en axilas de 2 meses de evolución, gions. de aparición espontánea, pruriginosos, que pro- Keywords: prurigo, pruritus, nodularis prurigo, chronic prurigo. gresivamente aumentan de tamaño. Antecedentes patológicos personales: no alérgico, asmático o atópico. Niega contacto con halógenos INTRODUCCIÓN (iodo o bromo). Esquema de vacunación comple- El prurigo nodular (PN) es una patología poco to (incluída la BCG) hasta la fecha de la consulta. frecuente, pruriginosa, de evolución crónica y por Antecedentes patológicos familiares: madre atópica. brotes, caracterizada por lesiones de aspecto Examen físico: Nódulos eritemato-violáceos nodular, múltiples o solitarias, que se ubican en las múltiples, vegetantes, de límites netos y bordes superficies extensoras de los miembros en forma regulares, distribuidos en forma simétrica en diseminada, con tendencia a la generalización. En ambas axilas y con descamación fina (Figuras 1 y las lesiones, habitualmente simétricas, agrupadas 2). Se observa liquenificación. Ausencia de ade- y numerosas, suele observarse una hiperpigmen- nomegalias. tación postinflamatoria perilesimal. Examen micológico directo y cultivo de la lesión y escamas: negativo para hongos. Rutina laboratorial: hemograma, VSG, glucemia, urea y creatinina normales. No se efectuaron estudios radiológicos. * Cátedra de Dermatología del Hospital de Clínicas. Estudio histopatológico: epidermis con acantosis Facultad de Ciencias Médicas. irregular, próxima a la hiperplasia pseudoepitelio- Asunción, Paraguay. matosa, hiperqueratosis y leve papilomatosis (Fi- Correspondencia: gura 3). Dermis papilar con infiltrado inflamatorio Dra. Beatriz Di Martino Ortiz linfohistiocitario perivascular, histológicamente [email protected] inespecífico. Presencia de ocasionales eosinófilos Recibido: 23-5-08 en el infiltrado (Figura 4). Colágeno orientado ver- Aceptado: 15-8-08 ticalmente en papilas dérmicas. No se observa Comunicaciones breves / Arch Argent Pediatr 2008;106(5):443-457 / 447 hiperplasia neural. No se efectuaron coloraciones taciones de inestabilidad neurocirculatoria. Se ha especiales. demostrado un aumento en el número de nervios y Diagnóstico anatomo-patológico final: prurigo células de Merkel en la dermis.10 Algunos autores nodular con cambios de liquen simple crónico so- sugieren que este hecho se halla ligado directamen- breimpuestos. te a la patogenia de este trastorno y no se observa en el liquen simple crónico. Es posible que neuro- COMENTARIO péptidos como la sustancia P y el péptido relacio- El prurigo es una dermatosis de etiología des- nado con el gen que codifica para la calcitonina, conocida, caracterizada por prurito intenso y contribuyan al prurito intenso, dado que son des- una erupción crónica o recurrente de tipo papu- encadenantes de la liberación de histamina. lonodular. Podría argumentarse que si la proliferación Se presenta con mayor frecuencia a los 20-50 neural que se observa en los prurigos fuera secun- años de edad y su frecuencia en niños es muy daria al traumatismo por rascado, hechos similares baja.4,5 podrían observarse en una piel liquenificada; no Se han detectado numerosos posibles factores obstante no se aprecian cambios o alteraciones en etiopatogénicos locales, como picaduras de insec- los neuropéptidos sensitivos en pacientes con li- tos, foliculitis y eccema numular, y otras causas quen simple crónico. sistémicas de prurito que pueden desencadenar Se ha postulado la existencia de dos formas prurigo nodular (PN), como estrés emocional, infec- distintas de prurigo nodular; una atópica de co- ción por micobacterias, enfermedad obstructiva bi- mienzo temprano y otra no atópica, de comienzo liar (intrínseca, extrínseca o por drogas), hepatitis C, tardío;9 en el primer grupo los pacientes presentan insuficiencia renal crónica, enfermedad de Hodgkin, hipersensibilidad cutánea a diversos alergenos leucemia, anemia, policitemia vera, estasis venosa, ambientales, junto a antecedentes de dermatitis tumores sólidos, síndrome carcinoide, hipotiroidis- atópica y en el segundo grupo no se detectaron mo e hipertiroidismo, diabetes, parasitosis, reaccio- reacciones de hipersensibilidad. nes a drogas, enteropatías inducidas por gluten u La dermatosis es bilateral con tendencia a la otra forma de malabsorción. De todos los trastornos simetría. De aspecto monomorfo, constituida por sistémicos asociados a PN, el más común en niños es lesiones nodulares, de tamaño variable (0,3-0,5 cm el linfoma de Hodgkin.6,7 Muchos de los pacientes de diámetro), en un inicio son lisas y brillantes, afectados tienen antecedentes personales o familia- salientes y sobreelevadas sobre la piel normal, de res de atopia y pueden presentar concentraciones consistencia firme al tacto y grado variable de elevadas de IgE sérica.8,9 Otros autores apoyan la liquenificación. teoría del traumatismo crónico debido a la fricción La evolución es crónica y no hay tendencia a la repetida por rascado persistente.4 resolución espontánea. Se considera una patología de origen neurogé- El diagnóstico diferencial debe plantearse con nico, puesto que se presentan numerosas manifes- FIGURA 2. Clínica. Las pápulas forman placas que muestran FIGURA 1. Clínica. Placas liquenoides distribuidas simétri- una coloración eritemato-violácea. Las lesiones se hallan camente en ambas axilas liquenificadas 448 / Arch Argent Pediatr 2008;106(5):443-457 / Comunicaciones breves el liquen plano hipertrófico, donde generalmente criocirugía o la fototerapia y el uso de vendas se observan lesiones típicas de liquen plano en elásticas oclusivas para bloquear el circulo vicioso otra localización. La hiperplasia pseudocarcino- prurito-rascado-prurito. Con el rasurado (curettage) matosa o pseudoepiteliomatosa puede observar- o extirpación quirúrgica, las lesiones reinciden en se en otros procesos inflamatorios y proliferativos el mismo sitio.8 crónicos, como bromoderma, iododerma, blasto- micosis, pioderma vegetante, hidradenitis CONCLUSIÓN supurativa o en el lecho de úlceras crónicas, como El prurigo es una dermatosis de etiología desco- la del pioderma gangrenoso, el lupus vulgar, es- nocida, que se ha intentado relacionar con varios crofuloderma y gomas. También con la escabiosis, factores etiopatogénicos, rara en infantes y de difí- urticaria y varicela. cil tratamiento. El PN es una afección muy pruriginosa, bastan- Presentamos el caso debido a la escasa frecuen- te resistente a las terapias convencionales, por lo cia de esta patología, sobre todo en su forma cróni- que su tratamiento acostumbra a ser limitado y ca en la infancia, y resaltamos la importancia del muy poco satisfactorio. estudio histopatológico, no solo para el diagnósti- Los antihistamínicos continúan siendo la tera- co de la enfermedad, sino para establecer el diag- pia de elección en esta patología y, en forma tópica, nóstico diferencial con otras dermatosis. los esteroides, que pueden incluso utilizarse en forma intralesional. BIBLIOGRAFÍA Para casos resistentes contamos con otras alter- 1. Accioly Filho JW, Nogueira A, Ramos -e- Silva M. Prurigo nativas, como la talidomida,11, 12 que sigue siendo el nodularis of Hyde-An update. J Eur Acad Dermatol Venereol 2000; 14 (2): 75-82. tratamiento más eficaz, inclusive como prueba te- 2. Rowland Payne CME, Wilkinson JD, McKee PH, et al. rapéutica; sus beneficios se relacionan con su ac- Nodular prurigo a clinicopathological study of 46 patients. ción sedante sobre el sistema nervioso central, lo Br J Dermatol 1985; 113: 431-439. que disminuye la percepción de estímulos periféri- 3. Fretzin DF. Prurigo nodularis. Arch Dermatol 1977; 113: 692- 693. cos, como el prurito y la neurotoxicidad directa del 4. Navarrete G, Medina D, Olguín
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