What Are Rheumatoid Nodules?

Appearance and Significance of Rheumatoid Nodules

Rheumatoid nodules
Dr. P. Marazzi/Science Photo Library/Getty Images

If you have rheumatoid arthritis, you may wonder whether developing rheumatoid nodules is inevitable. Rheumatoid nodules are seen in up to 35 percent of people with rheumatoid arthritis. As part of the disease process, firm, non-tender, subcutaneous nodules develop at pressure points, joints, and even in internal organs. Learn more about their significance and whether there is effective treatment.

Overview and Significance

Rheumatoid nodules are considered the most common cutaneous (skin) manifestation of rheumatoid arthritis. At initial presentation, when people are first evaluated for rheumatoid arthritis by a doctor, about 7 percent of them are found to have palpable, subcutaneous rheumatoid nodules. 

Rheumatoid nodules are commonly associated with joint deformity and serious extra-articular manifestations of rheumatoid arthritis, which may include involvement of the lungs or eyes. The nodules may vary in size during the course of the disease process. They may be associated with complications, including limited joint mobility, neuropathy, fistula formation, and infection.

About 75 percent of people with Felty's syndrome  (a severe type of rheumatoid arthritis) have rheumatoid nodules. Rheumatoid arthritis patients with nodules are more likely to develop vasculitis. Generally, it is thought that those with rheumatoid nodules have a more severe disease course with rheumatoid arthritis and more rapidly progressive joint damage.

Signs and Symptoms

Rheumatoid nodules can be subtle, painless masses. They generally measure between 2 millimeters and 5 centimeters. The nodules, which may appear as a single mass or as a cluster of nodules, usually develop when rheumatoid arthritis is active. The subcutaneous nodules are typically moveable and have a rubbery feel.

Some are bound to the periosteum (bone) and then feel firm or hard to the touch.

Common sites for rheumatoid nodules include the elbow, back of the forearm, metacarpophalangeal joints (knuckles), Achilles tendon, and extensor tendons.

Rheumatoid nodules are rarely found over the sacrum, occiput (back of the head), vocal cords, pulmonary parenchyma, pleura, pericardium, myocardium, or the leptomeninges of the central nervous system—but it is possible. It is also possible for rheumatoid nodules to develop within internal organs.  

Nodular masses are not exclusive to rheumatoid arthritis. Nodular masses can occur with gout (called gout tophi), rheumatic fever, xanthomatosis, and sarcoidosis, among other conditions. One distinguishing feature between rheumatoid nodules and gout tophi is that rheumatoid nodules rarely ulcerate or come through the overlying skin. There is also a well-known correlation between rheumatoid nodules and a high level of rheumatoid factor in a blood test.

Treatment

Intranodular steroid injections may reduce the size of a nodule. Treatment with DMARDs or TNF blockers may or may not eliminate rheumatoid nodules as rheumatoid arthritis is brought under control. Interestingly, some people treated with methotrexate experience worsening nodules, even if other aspects of the disease seem well-controlled.

Surgical removal is an option, but nodules tend to recur in as little as a few months, especially when they are present over an area of repeated trauma. Usually, for that reason, surgery is discouraged.

Sources:

Cush JJ, Weinblatt ME, Kavanaugh A. Rheumatoid Arthritis: Diagnosis and Treatment. West Islip, NY: Professional Communications; 2014.

Davis JM. Rheumatoid Nodules. UpToDate.

Firestein GS, Kelley WN. Kelleys Textbook of Rheumatology. Philadelphia, PA: Elsevier/Saunders; 2013.

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