Look for firm, circular lumps under the skin. These lumps are rheumatoid nodules, also known as subcutaneous (or under the skin) nodules. Seen in approximately 30% of cases, these lumps typically have diameters of less than 5 millimeters, ranging in size from small pea size to lemon sized lumps. They are usually found on the forearms, elbows, fingers joints, knees, bottom of feet/heel, the back of the hands, back of the head, the ear regions and inside the nose.These lumps are usually not painful, but they can be painful if the overlying skin becomes infected or ulcerated.The lumps will be the color of your skin. They are usually movable when applying pressure to them and feel doughy or firm.
Getting Treatment for Rheumatoid Nodules
Treat the nodules with disease-modifying antirheumatic drugs. The drugs used to treat rheumatoid nodules are known as disease-modifying antirheumatic drugs (DMARD) and work at the molecular level of the disease and drugs known as biologics which work by inhibiting specific immune system proteins.
DMARD drugs options include methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, azathioprine, and cyclosporine.Note that treatment of rheumatoid nodules is not required, but there is usually a spontaneous regression or reduction when a specific RA treatment is administered.Use caution with some DMARDs. Some medications may actually cause or worsen the nodules. These include methotrexate and leflunomide for unknown reasons.Tell your doctor if new nodules appear or the previous nodules are getting bigger or painful. You may need a new drug therapy to avoid the appearance of the nodules while treating the rheumatoid arthritis.
Try biologic drugs if your RA doesn’t respond to DMARDs. Your doctor might also recommend a biologic response modifier drug. These include etanercept, adalimumab, infliximab, certolizumab pegol, golimumab, anakinra, abatacept, rituximab, tocilizumab, or tofacitinib.
Many studies have been completed that saw reduction in these nodules when treating RA with these medications.Arrange an appointment with your doctor to discuss your treatment for Rheumatoid Nodules. Your doctor will give you a prescription for the medications you may need, and take these medications as directed.
Examine your skin for rheumatoid vasculitis. This is inflammation of the small and medium sized blood vessels of the skin cause by our body’s immune system. Up to 5.4% of people with longstanding/severe RA will experience rheumatoid vasculitis. It can affect many body parts and organs, but the skin is by far the most common site. The following are signs of rheumatoid vasculitis:
Purpura: Look for bruising of the skin known as purpura. Since the blood vessels are damaged, blood can leak out causing bluish or dark discoloration that resembles bruises.
Digital ischemia: The inflammation can lead to obstruction of blood vessels, which can be seen on the fingers as digital ischemia. When this happens, the fingers affected will turn dark and may become necrotic or gangrenous.
Ulcers: This is a superficial hole on the skin. Look for open sores or ulcers on the skin due to inflammatory obstruction of blood vessels.
Gangrene: Severely obstructed blood vessels can cause the affected areas skin to die and turn black or necrotic. When this happens, you may feel that the skin sounds crumply when applying pressure. You may also see pus oozing from the area, which is caused by bacteria growth from dead tissue. There may also be a foul smell and possibly pain at the site.Nail fold infarcts: These are small vessels obstructed around the area of the nail or fingertips. Since these vessels are really small, you may see small red or dark dots on the finger pads around the nai
Look for symptoms of neutrophilic dermatosis. The activation of our immune system’s white blood cells (neutrophils) infiltrates all layers of our skin, including the epidermis (outer layer) and dermis (inner layer). There are many diseases associated with this process that falls under neutrophilic dermatosis, some more common than others. Two conditions with this underlying disease process are known as pyoderma gangrenosum and sweet’s syndrome.
Pyoderma gangrenosum is characterized by painful, enlarging necrotic ulcers (open sores) with bluish undermined borders surrounded by a diffuse red rash.Sweet’s syndrome is also known as “acute febrile neutrophilic dermatosis.” The symptoms include fever, neutrophil inflammation, and painful plaques on the skin. There is also a diffuse underlying red rash that can appear on the arms, back, face and neck.The skin in this condition may peel or slough off. It is rarely seen in patients with Rheumatoid Nodules.
Diagnose and treat RA to improve other skin disorders. RA is a systemic disease which includes the skin. Treating the RA can drastically improve skin systems. Many of these treatments are used for RA and the skin disorders. Therefore, you should expect an overlap of treatment medications.The most important step is to seek expert advice with regards to diagnosing and testing for RA. Once diagnosis is confirmed, management of RA can help prevent these skin diseases.
Ask your doctor about steroid injections. Injecting steroids within the nodules have been proven to reduce size of the nodules. Therapy though may require weeks of injections by your healthcare provider.Steroids help reduce the inflammation process occurring at the nodules.
Your doctor will clean the area of the nodules with rubbing alcohol or alcohol pads. A numbing agent/spray or anesthetic may be applied to reduce pain. A needle with steroids will be injected at the site of the nodules.after receiving the shot, you may feel discomfort at the location, and flushing of the face or chest can occur. Do not excessively move the area, and apply ice to the site if pain occurs.Note if you are diabetic, steroids can increase your blood sugar.
Getting Treatment for Rheumatoid Vasculitis
Treating Pyoderma Gangrenosum
Prevent infections from developing in the wounds. Some forms of RA result in ulcers that need to be protected. Dress the wound with bandages, pads or gauze to prevent infections entering the wounds. Change these dressings every day and after showering.Your doctor may advise you to use a topical steroid cream under the dressing to reduce inflammation and/or pain. Discuss with your doctor on the appropriate cream to apply.
Get steroid injections. Your doctor may advise you to receive a steroid injection within the wound with the steroid Triamcinolone 40 mg/ml into the ulcer edge, either alone or as additional therapy.Your doctor will first clean around the injection site with alcohol pads. After the injection, he may advise dressing the wound including the site of injection to prevent infection.
Take oral steroids. Oral steroids are the mainstay therapy for this condition, Prednisolone is the drug of choice and is usually started at high doses (60-120 mg) tapered down to lower doses. Discuss with your doctor to establish what the starting dose should be and how long you should be on a certain dose of oral steroids before reducing the dose.Side effects of steroid use include increased blood sugar, weight gain, infections due to lower immunity (these drugs reduce the immune system’s inflammatory response), swelling, bruising and much more.It is not advised to stay on steroids for extended periods of time. Talk to your doctor to establish a timeline on when to stop using steroids.
Try an immunosuppressive drug as an alternative treatment. Cyclosporin is an immunosuppressive drug that can be used to reduce the dependence on steroids and, secondly, used as an alternative treatment if steroids fail to work. Your doctor will determine if you should try Cyclosporin. Then he will give you a prescription and proper dosing based on your weight. This drug can be taken as a capsule, liquid or injection; take as directed.Most patients show clinical improvement within three weeks with a dose of 3-5 mg/kg/day.
Combine steroids with DMARDs for mild cases. With cases of Rheumatoid Nodules vasculitis that affects the skin and/or nerves, make an appointment with your healthcare provider to discuss prescription medication regimens. Because this is an inflammatory process, taking steroids coupled with a disease-modifying antirheumatic drug (DMARD) such as methotrexate is considered first line therapy.Steroid doses range from 30 to 100 mg twice daily at onset for two to four weeks.Methotrexate starts with a dose of 10 mg/week increasing to a dose of 20 to 25 mg/week, based on the effectiveness and side effects. Exacerbation of vasculitis or occurrence of nodules may manifest but it is considered rare. Azathioprine can be substituted for methotrexate in doses of 50mg/day to 150 mg divided daily.
Take IV steroids at your doctor’s recommendation. Moderate or severe diseases is characterized by organ involvement such as the heart, nervous system or kidneys. Steroids administered by IV will act faster.The doctor will administer a maximum dose of 250 mg intravenously twice daily.IV steroids may be used in conjunction with the addition of a biologic drug and/or methotrexate. Several small case studies have been reported with successful usage of biologic.
Avoid smoking. Literature review studies have reported that smoking tobacco has a strong causal link with Rheumatoid Nodules. The cessation of tobacco use diminished RA vasculitis and extra-organ diseases, and with improved survival, points to a better outcome for patientsReach out to your healthcare provider, support groups, special counselors for tobacco quitting, and individuals who support your decision and want to help. Your doctor may assess your willingness to quit, then provide you with appropriate treatments such as nicotine gum, nicotine patch, counseling services or prescription medications such as Chantix. Counseling and medication together are more effective than either one alone.
Consider surgery for rheumatoid nodules. Excision of the nodules may be warranted if nodules remain, worsen, become infected or ulcerated, meaning that the skin is damaged and blood is exposed. The nodules may also be impinging on nearby nerves and producing sharp diffuse pain, and/or obstructing your everyday functioning, as would be the case with nodules on the foot.
Your surgeon will assess what kind of anesthesia to provide, either through injection at or around the site or through IV sedation. Your surgeon may ask you not to eat or drink anything after midnight the night before surgery.The area will be properly cleaned and the surgeon will use a scalpel or other cutting tool to cut the nodule. The surgeon may use a wide margin technique where an oval-shaped excision will be made around the nodule, removing the nodule and small amount of surrounding normal tissue to assure full removal. source