P056 Systemic signs of rheumatoid activity

Abstract

A 62-year-old man was referred to the dermatology department with a rash on the extensor surfaces of his thighs, haemorrhagic papules on the pulp of the digits and new subcutaneous nodules. He had a history of seropositive rheumatoid arthritis (RA), which had been treated successfully with etanercept, although he had recently developed secondary failure. On examination, there were erythematous plaques on the thighs bilaterally. There was no scale and satellite papules were noted. He had been treated by his general practitioner for a presumed psoriasis with calcipotriol–betamethasone. On his hands there were numerous, asymptomatic purpuric papules on the fingertips, with some showing necrosis. Nailfold haemorrhage was also evident on capillaroscopy. Numerous subcutaneous nodules were noted on the hands and forearms that had developed rapidly in the preceding weeks. His clinical features were in keeping with Bywaters lesions and accelerated rheumatoid nodulosis. Biopsy of the rash on his thigh confirmed rheumatoid neutrophilic dermatitis, showing a superficial and deep dermal inflammatory infiltrate. Bywaters lesions, typically benign in nature, indicate small-vessel vasculitis with no association with systemic vasculitis. Accelerated rheumatoid nodulosis presents with rapid development of numerous subcutaneous nodules, often affecting the hands and feet. This has been reported in patients on established disease-modifying treatment, including etanercept, as in our case. Rheumatoid neutrophilic dermatitis is a rare systemic presentation of RA, presenting with symmetrical, asymptomatic papules or plaques, often in an annular configuration on the extremities. Rheumatoid neutrophilic dermatitis, Bywaters lesions and accelerated nodulosis are important cutaneous signs of severe seropositive RA. Such signs can present despite biologic treatment, and indicate a high burden of disease activity. The identification of these signs is important as adjustment of medication can often lead to resolution of symptoms and improved control of joint disease.