Discussion
Dermatological complications in RA patients can be specific or related
to skin disease due to the treatment taken by a patient
(11). RA specific skin lesions are seen
only in RA patients and include accelerated rheumatoid nodules,
rheumatoid vasculitis, rheumatoid nodules and RND
(8). Rheumatoid arthritis-related skin
diseases include dermatoses that are associated with RA
(12, 13).
This group of skin disorders includes pyoderma gangrenosum, sweet’s
syndrome, Raynaud’s phenomenon and erythema elevatum diutinum (EED). RND
was first described by Ackerman in the last century. It is a rare and
distinct manifestation of RA with high frequencies in females compared
to males; only less than 20 cases had been described until now
(14, 15).
The prevalence of RND is less than 2% among all RA patients
(16). The exact pathophysiology of the
condition is unknown; however, it is believed to be an
immune-complex-mediated disease (17). RND
commonly appears in patients with severe, chronic seropositive arthritis
and clinically manifests as asymptomatic nodules, erythematous papules
and urticaria-like lesions (7,
8). The dermatological lesion in RND can
be either palpable purpura, or plaque or nodule in the Extensor surfaces
of extremities and joints are favoured locations as in our presenting
patient who showed nodulopapular lesions in the thighs and the lower
part of the abdomen (7,
18). The differential diagnosis was
considered and ruled out, which includes dermatitis herpetiformis ruled
out by the absence of bullous lesions, A drug eruption was also ruled
out because the lesions persisted and worsened in spite of cessation of
medications, sweet syndrome was also excluded as the patient was not on
any of the medications that can cause a Sweet’s-like drug
hypersensitivity (19). Behcet’s disease,
bowel-associated dermatosis arthritis syndrome and pyoderma gangrenosum
were ruled Out by history and absence of ulcerative or vesiculopustular
lesions. Erythema elevatum diutinum was ruled out by the absence of
vasculitis (20).