Skin Problems in Rheumatoid Arthritis

Nodules, vasculitis, and more

Rheumatoid arthritis (RA) is a systemic autoimmune disease that affects the entire body. It results when the immune system attacks its own healthy tissues because it thinks they are diseased. Most of the time, RA is characterized by joint pain and inflammation and in severe cases, the inflammation also affects the body’s organs.  

RA is also associated with a number of skin conditions and the severity of skin involvement indicates how severe the disease is. In addition, the medications that treat it may also affect the skin. 

Rheumatoid Nodules

Subcutaneous nodules affect up to 25 percent of people with rheumatoid factor (RF) positive RA. RF is a protein produced by the immune system, causing it to attack healthy issues. 

Nodules are hard lumps of tissue that form under the skin of bony areas, including the elbows, ankles, and fingers. They can even form on the organs, especially the lungs. They range from about the size of a pea to the size of a golf ball.

Treatment for large nodules includes disease-modifying anti-rheumatic drugs (DMARDs) or corticosteroid shots to help reduce the size of nodules. Small nodules usually do not need treatment. Some people may need surgery to remove nodules that become extremely large and/or painful and/or become infected. 

Vasculitis

According to the Vasculitis Foundation, 1 in 9 people with RA will develop rheumatoid vasculitis (RV). This complication is more common in people who have had RA for a decade or more. RV causes inflammation in the blood vessels of the skin.  

RV affects blood vessels that supply blood to the fingers and toes, causing redness and sores on the tips of the fingers and toes and pitting around the nails. In the most serious cases, RV can even cause digital ischemia, as well as damage and destruction of the skin and underlying tissues.

RV can also affect larger blood vessels, causing rashes in larger areas, such as the legs. Skin ulcers (crater-like open sores) may also form and become infected.

Treatment of RV is dependent on its severity. Prednisone is a first-line treatment for RV. Controlling RA, generally, is the best way to manage RV. If RV has caused ulcers and affected organs, cyclophosphamide, a chemotherapy agent is a considered treatment. 

The good news is that RV prevalence has declined in recent years due to better treatment options and reduced incidences of RA progression.

Livedo Reticularis

Livedo reticularis is a skin condition that is not generally associated with RA, although some research indicates it is common in people with rheumatoid vasculitis. Livedo reticularis rashes tend to be harmless and are more common with colder weather. This condition causes spasms in blood vessels that cause a net-like purplish appearance on the skin. Livedo reticularis may cause ulcers, nodules, and discoloration.

Hives

Some people with RA experience recurrent hives on their skin. These look like rashes with red itchy bumps and are similar to what is experienced as a medication side effect, but form separate from medication use.

Medication Side Effects

Some medications that treat RA can cause skin rashes, hives, thinning skin, bruising, and sensitivity to sunlight, and may even interfere with blood clotting.

DMARDs and nonsteroidal anti-inflammatory drugs (NSAIDs) may cause rashes and hives. This is generally an allergic reaction and should be brought to the attention of one’s doctor. NSAIDs and DMARDs may also cause sun sensitivity. When taking these medications, it is a good idea to avoid direct sunlight and tanning beds and use sunscreen when outdoors.

Aspirin and corticosteroids are known for interfering with blood clotting. They may also thin out skin and cause bruising. 

Treatment of Skin Issues

Some skin issues may require treatments, while others might not. Treatment will depend on the cause and severity. The goal of treatment is to reduce pain, discomfort, and inflammation, and also to prevent infection.

It is very important to treat the underlying cause of skin problems, as these conditions are a sign that rheumatoid arthritis symptoms are not well-managed.

Common over-the-counter (OTC) medications, including acetaminophen (Tylenol), can help with pain, while NSAIDs, including ibuprofen, can help control and reduce inflammation. Severe pain may need prescription NSAIDs. Corticosteroids can also help reduce skin inflammation, but these medications cannot be used in the long-term. If there is a possibility of infection, a topical or oral antibiotic may be prescribed. Hives are usually treated with antihistamines.

If medications are the cause of RA skin symptoms, medication replacement or reduction may help prevent or reduce skin symptoms. 

A Word From Verywell

There is no way to prevent rheumatoid arthritis skin issues. Doctors will try different therapies to manage all RA symptoms. The good news is that serious skin complications are rare these days and they are becoming less common due to new medications for treating RA. Furthermore, all skin issues can be treated and managed effectively, especially if caught early on.

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Article Sources
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  • Sajjan VV, Lunge S, Swamy MB, Pandit AM. Livedo reticularis: A review of the literature. Indian Dermatol Online J 2015; 6:315-21. DOI: 10.4103/2229-5178.164493.

  • The Vasculitis Foundation. Rheumatoid Vasculitis. Updated September 2012.

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