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Rheumatoid Nodules: Causes, Symptoms & Treatment

Rheumatoid nodules are firm lumps of tissue that form under the skin, most commonly in patients with rheumatoid arthritis. They are a classic sign of advanced disease.

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Things worth knowing about "Rheumatoid nodules"

Rheumatoid nodules are firm lumps of tissue that form under the skin, most commonly in patients with rheumatoid arthritis. They are a classic sign of advanced disease.

What Are Rheumatoid Nodules?

Rheumatoid nodules are firm, palpable lumps of tissue that develop beneath the skin. They occur most frequently in patients with rheumatoid arthritis (RA) and represent one of the most characteristic extraarticular manifestations of this condition. The nodules can range in size from a few millimetres to several centimetres and are usually painless, though they may cause discomfort when pressure is applied to sensitive areas.

Causes and Development

The exact cause of rheumatoid nodules is not yet fully understood. It is believed that local inflammation of small blood vessels (vasculitis) triggers the formation of these nodules. The immune system attacks the body's own tissue, leading to an accumulation of inflammatory cells and thickening of connective tissue.

Preferential occurrence at pressure points, such as the elbows, finger joints, or heels
Strong association with a positive rheumatoid factor (RF) in the blood
More common in patients with severe or long-standing rheumatoid arthritis
Smoking is considered a risk factor for the development of rheumatoid nodules
Certain medications (e.g. methotrexate) can paradoxically promote the formation of nodules

Symptoms

Rheumatoid nodules are often asymptomatic but can cause various complaints depending on their location:

Palpable, hard or rubbery lumps beneath the skin
Pressure pain under mechanical stress (e.g. at the heel when walking)
Restricted mobility when located near joints
In rare cases, ulceration (skin sores) may develop over superficial nodules
Internal organs such as the lungs or heart can be affected in rare cases (visceral rheumatoid nodules)

Common Locations

Rheumatoid nodules tend to develop at sites exposed to mechanical pressure:

Extensor surface of the forearm, near the elbow
Finger joints and knuckles
Heel bone and Achilles tendon
Back of the head (in bedridden patients)
Less commonly: lungs, heart valves, eyes (sclera)

Diagnosis

The diagnosis of rheumatoid nodules is primarily clinical, based on physical examination and inspection. The following investigations may be used to supplement the clinical assessment:

Ultrasound: To assess the extent and depth of the nodule
MRI (Magnetic Resonance Imaging): For unclear diagnoses or suspected internal involvement
Biopsy: Tissue sampling for histological confirmation, showing characteristic granulomatous inflammation with central necrosis
Blood tests: Detection of rheumatoid factor (RF) and anti-CCP antibodies

Treatment

Rheumatoid nodules themselves usually do not require specific treatment. The primary focus is on managing the underlying rheumatoid arthritis:

Medical Treatment

Disease-modifying antirheumatic drugs (DMARDs) such as hydroxychloroquine may contribute to a reduction in nodule size
Methotrexate (MTX) can paradoxically promote the development of new nodules (so-called methotrexate-induced nodulosis)
Biologics (e.g. TNF inhibitors) may be used in severe cases
Local corticosteroid injections to reduce the size of individual nodules

Surgical Treatment

Surgical removal of rheumatoid nodules is only recommended in exceptional cases, such as:

Severe pain or functional limitations
Recurrent infections or ulcerations
Nodules causing significant cosmetic concern

Since rheumatoid nodules frequently recur after surgical removal, a careful risk-benefit assessment is essential before proceeding with surgery.

Prognosis

Rheumatoid nodules are generally benign and do not pose an immediate threat to health. However, they may indicate active or severe rheumatoid arthritis. With optimal medical treatment, they can regress over time. Patients with rheumatoid nodules have an overall higher risk of systemic complications and should receive close rheumatological follow-up.

References

Firestein GS, Budd RC, Gabriel SE et al. - Kelley & Firestein's Textbook of Rheumatology, 10th Edition. Elsevier, 2017.
Turesson C, Jacobsson LT - Extraarticular manifestations of rheumatoid arthritis. In: Rheumatic Disease Clinics of North America, 2004.
Smolen JS, Landewe R, Bijlsma J et al. - EULAR recommendations for the management of rheumatoid arthritis. In: Annals of the Rheumatic Diseases, 2020.

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