Extra-articular manifestations
- Rheumatoid nodules
- Clinical presentation
- Firm, semi-mobile papulonodules
- Periarticular locations over areas subject to pressure or trauma
- Extensor surfaces (olecraneo, back or forearm)
- Histology
- Palisade granuloma
- Deep dermis or subcutis
- Central zone of brightly eosinophilic fibrin
- Surrounded by layer of histiocytes and granulation tissue
- Accelerated rheumatoid nodulosis
- Following intiation of MTX, TNF inhibitors, leflunomide, tocilizumab
- Treatment
- Surgical excision → recurrence is common
- Intralesional corticosteroids
- Rheumatoid vasculitis
- May affect vessels of any size
- Small vessel → palpable (and non-palpable) purpura
- Medium vessel → nodules, ulceration, necrotizing livedo reticularis, digital infacts
- Systemic complications: neuropathies (mononeuritis multiplex), cerebral infarctions, scleritis, alveolitis, carditis, intestinal ulcers, proteinuria
- Treatment
- Intravenous methylprednisolone (500-1500mg/day for 3 days)
- Followed by prednisone (1mg/kg/day) plus cyclophosphamide (daily or monthly)
- Plasmepheresis
- Felty syndrome
- Granulocytopenia, splenomegaly, therapy resistant leg ulcers (often pre tibial)
- Treatment: granulocyte colony-stimulating factor and/or splenectomy
- Rheumatoid neutrophilic dermatitis
- Resembles Sweet Syndrome
- Erythematous urticarial papules and plaques
- Treatment: antineutrophilic agents (dapsone, colchicine)
- Diseases more common in Rheumatoid Arthritis
- Pyoderma gangrenosum
- Erythema Elevatum Diutinum (EED)
- Palisaded Neutrophilic and Granulomatous Dermatitis (PNGD)
- Intralymphatic histiocytosis
- EBV associated lymphoproliferative disease
Treatment of Rheumatoid Arthritis
- NSAIDs
- Low-dose systemic corticosteroids
- Disease modifying antirheumatic drugs
- Hydroxichloroquine
- Leflunomide
- Methotrexate
- Sulfasalazine
- Biologic immunomodulators
- TNF inhibitors
- Abatacept
- Tocilizumab
- Rituximab
- JAK inhibitors
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