VEGFA and Hyperkeratosis: Prurigo nodularis is also associated with disturbed neuronal architecture (increased epidermal neuronal branching and dermal neuronal hyperplasia) and dysregulation of neuropeptides that may contribute to inflammation.13,14,15,16 Epidermal dysregulation is seen as a result of these processes, characterized by epidermal hyperplasia and hyperkeratosis, as well as proinflammatory vascularization processes in the dermis through activation of vascular endothelial growth factor (VEGF).17,18,19