Common Cutaneous manifestations of rheumatoid arthritis, including deformities of rheumatoid arthritis and radiological changes,

1. CUTANEOUS MANIFESTATIONS OF
RHEUMATOID ARTHRITIS
SUJITHA TAMILSELVAM
CRRI
PONDICHERRY INSTITUTE OF MEDICAL SCIENCES

2. RHEUMATOID ARTHRITIS
 Rheumatoid Arthritis (RA) is a immune-mediated,
chronic disease affecting selected joints
 Characterized by persistent inflammatory synovitis
leading to cartilage damage, bone erosions, joint
deformity and disability.
 In Extra -articular localizations, skin being the most
commonly affected organ, with polymorph clinical
manifestations

3. OVERVIEW
 Age: Any age, commonly 3rd to 6th decade
 Female: male 3:1
 pattern of joint involvement could be:-
1) Polyarticular : most common
2) Oligoarticular
3) Monoarticular
 Morning joint stiffness > 1 hour and easing with
physical activity is characteristic.
 Small joints of hand and feet are typically involved.

4. 2010 ACR/EULAR CRITERIA

5. CLINICAL FEATURES
ARTICULAR
EXTRA – ARTICULAR

6. ARTICULAR MANIFESTATIONS
JOINT INVOLVEMENT PERCENTAGE
MCP, PIP 91
WRISTS 78
KNEES 64
SHOULDERS 65
ANKLES 50
FEET 43
ELBOWS 38
HIPS 17
TMJ 8
SPINE 4
PERI ARTICULAR SITES 27

7. EXTRA – ARTICULAR MANIFESTATIONS

8. EXTRA – ARTICULAR MANIFESTATIONS
EXTRAARTICULAR
MANIFESTATION
INCIDENCE
Pericarditis 2.6
Pleuritis 1.9
Major cutaneous vascultis 0.6
Vasculitis – related neuropathy 0.2
Felty syndrome 0.5
Scleritis 0
Episcleritis 0.7
Secondary sjogren syndrome 9.6
Pulmonary fibrosis 5.0
Bronchiolitis obliterans 0.7
Subcutaneous rheumatoid nodules 31.2

9. CUTANEOUS MANIFESTATIONS
SKIN MANIFESTATIONS OF RHEUMATOID ARTHRITIS
GENERAL
•Erythema , burning sensation (may precede joint changes)
•Nodules
•Atrophy
•Vitiligo (non – segmental )
•Possible association with pseudoxanthoma elasticum
VACULITIS
•Splinter haemmorhages and periungual infarcts
•Palpable purpura
•Livedo reticularis
•Atrophie blanche
NEUTROPHIL RELATED DISORDERS
•Pyoderma gangrenosum
•Rheumatoid neutrophilic dermatoses
MISCELLANEOUS
•Vasculitis , venous insufficiency, lymphoedema, inactivity, skin atrophy
•Interstitial granulomatous dermatitis
•Intralymphatic histiocytosis

10. CUTANEOUS MANIFESTATIONS
 SPECIFIC
 NON SPECIFIC

13. ATROPHIC SKIN WITH RA
 >60 Years
 F > M
 Skin – dorsa of hand – thin, loose, inelastic
transparent – tendons and veins clearly seen
 Histologically dermis is thinned

15. CLASSICAL RHEUMATOID NODULES
 Subcutaneous lesions, skin-like colored, with a
diameter generally ranging from >5mm to several
centimeters.
 The extensor surfaces of the forearms, the back of
the hands, the occipital regions, the auricular
regions and the nasal pyramid
Other sites
 Larynx
 Heart , lungs
 Brain – leptomeninges > parenchyma
 Vertebral body – signs of myelopathy

16. RHEUMATOID NODULES – PATHOGENESIS
 Resident histiocytes and fibroblast proliferation to
an influx macrophages
 cytokine mediated – TNF, IL- 1 , IL- 12 , IL – 17
 Th1-mediated pathogenetic hypothesis
HISTOLOGY:
 Palisaded granulomas – deep dermis or
subcutaneous tissues
 Focal central fibrinoid necrosis – surrounding
fibroblasts

17. HISTOLOGY PIC

21. DIFFERENTIAL DIAGNOSIS – RHEUMATOID
NODULES
 Subcutaneous granuloma annulare
 Foreign body granuloma
 Infectious granuloma
 Sarcoid granuloma
 Myxoid cyst
 Traumatic epidermal cyst
 Xanthoma
 Epitheloid sarcoma
 Fibromatous nodules in lyme borreliosis

22. RHEUMATOID NODULOSIS
 Multiple nodules in the hand
 Positive RF
 Acute intermittent synovitis
 Subchondral cystic lesions of the small bones of
hands and feet

23. RHEUMATOID VASCULITIS
 Seen in 0.1 to 5.4 %
Can present as
 Distal arteritis - Splinter haemorrhages, periungaul
infarcts , gangrene
 Cutaneous ulceration – pyoderma gangrenosum
 Peripheral neuropathy – mononeuritis multiplex /
sensory stocking glove neuropathy
 Palpable purpura
 Arteritis of the viscera

25. RHEUMATOID VASCULITIS
 Livedo reticularis
High titres – RF & anti-CCP
Pathology :
 Panarteritis – all layers of vessel infiltrated with
mononuclear cells
 Fibrinoid necrosis
 Thrombosis , obliterative endarteritis
 Immune complex deposits

26.  Neurovascular disease manifest as
Mild distal sensory neuropathy
Severe sensorimotor neuropathy (mononeuritis
multiplex)
C/F –
Burning feet
Weakness ex: footdrop
Visceral lesions – claudication/ infarction
Gangrene of digits , extremities

27. Small vessel vasculitis involving
lower legs

28. LIVEDOID VASCULOPATHY

30. Periungual
granuloma
pyogenicum

32. NEUTROPHILIC DERMATOSIS
 Neutrophilic dermatoses are a wide group of
diseases characterized by neutrophil accumulation
in the skin and in extracutaneous sites.
 Include disorders like pyoderma gangrenosum and
Sweet syndrome – can co-exist in one patient
 Usually associated with Blood cell dyscracias , IBD,
Rheumatoid arthritis , systemic lupus
erythematosus

34. RHEUMATOID NEUTROPHILIC
DERMATOSIS
C/F
 Urticaria like papules and plaques – symmetrical on
the trunk and limbs
 Overlap with sweet syndrome
 Tense bullae can occur in lower limbs
 Histology :
 Heavy dermal infiltrates of neutrophils, no frank
vasculitis

36. PYODERMA GANGRENOSUM
 A type of neutrophilic dermatosis
 Pyoderma gangrenosum typically - sterile pustules
which rapidly evolve into painful ulcers,
 Wide and deep, characterized by well-defined and
raised edges of erythematous-purple coloring

39.  Overlap between – pyoderma gangrenosum and
sweets syndrome
 Between pyoderma gangrenosum and rheumatoid
neutrophilic vasculitis

40. SWEET’S SYNDROME
 “acute febrile neutrophilic dermatosis”
 onset of fever, neutrophil leukocytosis, and painful
plaque erythematous skin lesions
 Including bullous, pustular, subcutaneous and giant
cellulitis-like forms
 Histology :
 Dense neutrophilic infiltrate in the superficial
dermis, with considerable edema; another possible
variant is the “histioid” form, while the presence of
eosinophils in the infiltrate suggests a drug-induced
form

41. INTERSTITIAL GRANULAMATOUS
DERMATITIS
 Defined as interstitial granulomatous dermatitis
with arthritis
 Papules and erythematous plaques, erythematous-
purple lesions, in 10% of the cases with a typical
“cord-like” appearance,
 With symmetric distribution; the most affected sites
being the axillary area, the trunk and the medial
surface of thighs
 Interstitial histiocytic granulomas without vasculitis
and mucin deposit

42. DEFORMITIES IN RHEUMATOID ARTHRITIS
Patient with rheumatoid arthritis presenting with a radial
deviation
(right wrist), swan-neck deformity with hyperextension of the
proximal
interphalangeal (PIP) and fl exion of distal interphalangeal
(DIP) joints

43. Patient with rheumatoid arthritis presenting with volar
subluxationof the right hand with a visible sliding at the
radiocarpal joint and Z-deformity
(thumb) with flexion of the first metacarpophalangeal joint and
hyperextension of the interphalangeal joint.

44. Typical forefoot deformities in a patient with
rheumatoid arthritis with
clawing of the toes and dislocation of the
metatarsophalangeal (MTP) joints.

47. RADIOGRAPHIC FEATURES
 Peri-articular osteopenia
 Uniform symmetric joint space narrowing
 Marginal subchondral erosions
 Joint Subluxations
 Joint destruction
 Collapse
 Ultrasound detects early soft tissue lesions.
 MRI has greatest sensitivity to detect synovitis and
marrow changes

50.  Thank you