by Dr. C.H. Weaver M.D. updated 7/2020
Rheumatoid arthritis (RA) is an autoimmune disease, and, as such, it can affect the entire body, particularly if the RA becomes severe.1 In addition to joint problems, people with RA may notice occasional fevers, fatigue, and a sense of being generally unwell. Rheumatoid arthritis can lead to anemia (low red blood cell count) and, less commonly, to problems with the blood vessels, lungs, heart, and other organs. Rheumatoid nodules are another manifestation of RA and effect 20% to 35% of adults.
Rheumatoid nodules are firm lumps located just under the skin. The nodules most commonly grow close to the affected joints and can be as small as a pea and as large as a chestnut. The nodules can be firmly connected to tendons or fascia under the skin or quite moveable. Rheumatoid nodules are also often found at pressure points, including the hands, fingers, knuckles, or elbows; however, they may appear almost anywhere, including the lungs, heart, other internal organs, and even on the vocal cords, causing hoarseness.
Nodules can be asymptomatic or quite painful, but they are typically not problematic unless they interfere with daily activities by putting pressure on nerves or by limiting joint movement. Rheumatoid nodules in areas such as the heart and lungs may affect organ function.
What are the causes of rheumatoid nodules?
Rheumatoid arthritis is the primary cause of rheumatoid nodules, but some people with the disease are more susceptible to nodules than others. Rheumatoid nodules are also a sign of inflammation and heightened immune system activity and usually occur in patients with more severe disease or poorly controlled disease. Nearly all patients with nodules will test positive for rheumatoid factor, and studies have suggested that when RA is linked with a positive rheumatoid factor test, it may indicate more aggressive disease.
High rheumatoid factor levels may be the most significant risk factor for rheumatoid nodules. About 40% of people with high levels of rheumatoid factor develop nodules.
Other risk factors that may lead to the development of rheumatoid nodules include cigarette smoking and the use of Methotrexate, a drug commonly used to treat RA.
What are the risk factors for getting rheumatoid nodules?
Some risk factors make rheumatoid nodules more likely.
- Taking methotrexate or other arthritis drugs: Ironically treatment with methotrexate can cause a condition called methotrexate-induced accelerated nodulosis which causes nodules on the feet, hands, and ears in ~ 8%–12% of patients receiving the drug for rheumatoid arthritis.
- Trauma near a pressure point: People are more likely to develop rheumatoid nodules on pressure points, cuts or bruises.
- Severe rheumatoid arthritis: People with more serious symptoms are more likely to develop nodules most likely because people with active disease also have high levels of rheumatoid factor.
- Smoking: Some studies suggest that people who smoke may be more vulnerable to developing rheumatoid nodules.
Can rheumatoid nodules be treated?
Treatment of rheumatoid nodules is typically directed at nodules causing symptoms or functional problems. Injections of glucocorticoids (steroids) may help shrink nodules; sometimes surgery is necessary if rheumatoid nodules become infected or cause severe symptoms.
There is no specific drug therapy directed at treating rheumatoid nodules; however, disease-modifying anti-rheumatic drugs (DMARDs) can reduce the size of rheumatoid nodules. If nodules are thought to be a result of methotrexate treatment, a change in medication regimen may help; however, this decision must be carefully made on an individual basis.
Physical therapy is important to retain mobility and reduce pain. Nodules that are painful or present a cosmetic concern can be surgically removed, however doctor will not often recommend surgical removal of a nodule because they frequently return.
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- Young A, Koduri G. Extra-articular manifestations and complications of rheumatoid arthritis. Best Practice & Research Clinical Rheumatology. 2007;21:907-27.