Beyond rheumatoid nodules in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease predominantly affecting synovial joints. Extra-articular manifestations, including skin involvement, can also occur. The most frequent cutaneous manifestation in RA patients is rheumatoid nodules, occurring in 20-30% of seropositive individuals. These nodules are typically firm, painless, and located on pressure points such as the hands and elbows. However, in a minority of cases, other skin conditions can complicate RA, notably palisaded neutrophilic granulomatous dermatitis (PNGD). PNGD presents as erythematous papules or plaques, often pruritic and distributed symmetrically over extensor surfaces, making it challenging to differentiate from rheumatoid nodules. Histopathological examination is crucial to establish the diagnosis. High clinical suspicion and appropriate referral to Dermatology are essential for accurate diagnosis and management. Treatment of PNGD is focused on underlying disease control. Other options include topical, intralesional or systemic corticosteroids, dapsone or hydroxychloroquine. Herein, we present the case of a 71-year-old woman with RA who developed PNGD, highlighting the importance of a multidisciplinary approach for achieving a favorable clinical outcome.