Two years ago, TLC aired an episode about a young Black woman named Natalie who broke out in tears while describing a condition that mysteriously appeared all over her skin. She showed her arms and legs to the camera, displaying a series of evenly spaced, raised, pigmented nodules, and described an intense need to scratch them. She appeared on the show after suffering from the condition for 7 years and seeing multiple dermatologists. The nodules were spread across her legs, thighs, arms, abdomen, and some parts of her back. The more she itched, the thicker the nodules became.
She saw multiple dermatologists, she was prescribed topicals and bleach creams, she tried multiple diets and herbals, but nothing worked. It was only after she did her own research that she began to suspect that she may have a condition known as prurigo nodularis (PN).
The episode then follows her to a dermatologist’s visit. The dermatologist confirmed the diagnosis, but then went on to say that it is not actually a condition, but that “prurigo nodularis” is just a descriptive term. After examining her skin, the doctor becomes convinced that the bumps are a result of the itching and the itching, though very really, is a compulsion in her mind. The patient responded confidently, “I definitely don’t think it’s THAT.”
And by that, Natalie is correct. PN is a pathological condition that researchers now recognize is due to neuroimmune dysregulation leading to an itch-scratch cycle. [1] When researchers examined lesional skin histologically, they noted dense infiltration of pro-inflammatory cells. These pro-inflammatory cells release cytokines, such as IL-4, IL-31, as well as histamine, prostaglandins, and other mediators of itch and inflammation. [1] Some of these cytokines are now the basis of current and emerging therapies.
Natalie’s frustration with her providers, treatment, and diagnostic delay is a common theme for those who suffer from PN, with many suffering for years before an accurate diagnosis is established. African Americans and Black individuals are 3 to 4 times more likely than Caucasians to have PN. [2] Unfortunately, American society has a long history of marginalizing diseases that disproportionately affect African Americans. In 1850, Dr. Samuel Cartwright invented a convenient mental illness (“dyaesthesia Aethiopis”) that he purported led to an insensitivity towards pain when slaves were subjected to punishment. This propagated the narrative that Black people did not feel pain like White people did. [3] As a result, many painful ailments that disproportionately affected Black individuals were marginalized, ignored, and understudied, like sickle cell anemia. [3]
PN similarly falls into this category of diseases that disproportionately affect African Americans and Black individuals. It is no wonder why many of Natalie’s doctors and dermatologists did not recognize what she had. It is amazing that, in our day and age, a doctor can look at Natalie’s suffering and tell her it is all in her head, that she is part of the problem, and her solution is to just stop herself from itching. Natalie protests and says there is a sensation that is making her itch. Her doctor tells her it is an obsessive compulsion to pick at it because something about it bothers her.
Natalie is talking, and her doctor is clearly not listening. To her doctor, it is just an itch, nothing serious. Stop her from itching, and the problem Natalie has created for herself will go away. Meanwhile, Natalie cannot talk to the camera about her PN without crying. She is unconvinced; but because she is desperate, she moves forward with the doctor’s treatment plan, which involves more topicals an Unna boot.
Do not be like Natalie’s doctor. It is not just in her head. It is not just an itch; it is our society, once again, ignoring the pain and suffering of African Americans. It is real and now, for the first time in history, there is medication approved to treat it. Learn to recognize PN better, diagnose it earlier, and treat it appropriately. Do not be like Natalie’s doctor.
For more, check out the following CE activity below, expiring soon!
What Lies Beneath: Current and Emerging Treatments for Prurigo Nodularis – RMEI
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