Leg Ulceration in Rheumatoid Arthritis – An Underreported Multicausal Complication with Considerable Morbidity: Analysis of Thirty-Six Patients and Review of the Literature

Abstract

Background: Rheumatoid arthritis (RA) is a systemic inflammatory disease which may present with extra-articular symptoms, including cutaneous manifestations. Ulcerated rheumatoid nodules, necrotic vasculitic lesions and pyoderma gangrenosum are fairly characteristic and well-recognized causes of skin ulcers in RA. However, most RA patients develop leg ulcers due to other pathophysiological factors posing a diagnostic and therapeutic challenge and leading to considerable morbidity. Methods: A retrospective chart analysis of all patients with RA and leg ulcers hospitalized at our Dermatology Department between January 1998 and March 2008 was performed to evaluate risk factors and identify underlying conditions that predispose RA patients to the development of leg ulcers. Results: A total of 36 patients with RA and leg ulcers were identified. Three patients presented with necrotizing vasculitis and 2 with pyoderma gangrenosum. Chronic venous insufficiency was diagnosed as the underlying cause of leg ulcers in 8 patients, peripheral arterial disease in 4 patients, and combined arterial and venous malfunction in 3 patients. Five patients suffered from pressure ulcers. Interestingly, in 11 patients (31%) other underlying causes besides constricted mobility followed by secondary lymphedema could not be identified, and these ulcers were classified as ‘inactivity leg ulcers’. Conclusions: The majority of leg ulcers in patients with RA are due to underlying venous/arterial malfunction while vasculitic or traumatic ulcers are less common. Additionally, we identified a relevant subgroup of patients with ‘inactivity ulcers’ due to impaired mobility and consecutive lymphedema. Morphology and localization of ulcerations as well as duplex sonography provide the most important clues for accurate diagnosis, ensuring adequate treatment.

Pressure Bandage as an Effective Treatment for Intralymphatic Histiocytosis Associated with Rheumatoid Arthritis

“…Their findings suggest that local inflammatory response, as well as congestion of lymph channel, should be a necessary requirement for the development of this disease. Seitz et al [10] suggested that impaired morbidity and consecutive lymphedema are responsible for leg ulcerations in a considerable proportion of patients with RA, although it had been believed that vasculitis and pyoderma gangrenosum account for the majority of cases. Intralymphatic histiocytosis and leg ulcers thus seem to share some pathogenic factors in the sense that lymphostasis is an important precipitating factor and compression may be an effective treatment.…”

Mucocutaneous manifestations in patients with rheumatoid arthritis: A cross-sectional study from Eastern India

“…Morphology and localization of ulcerations, as well as Doppler ultrasonography, present the vital clues for accurate diagnosis, ensuring proper treatment. [19] About 2.7% of patients of a previous series had leg ulcers. [6] A relatively higher percentage (9.9%) of patients of the present series had such problem.…”

Occurrence and Effect of Lower Extremity Ulcer in Rheumatoid Arthritis — A Population-based Study

“…Three of the 16 patients with LE ulcers in this study (17) had biopsy proven vasculitis but it is unclear whether these results can be generalized as the sample size was small. Vasculitis was less common in LE ulcers in patients with RA in another institution-based retrospective study of hospitalized patients from a dermatology servicedivision (23). …”