Rheumatoid nodules: new recommendations

The incidence of rheumatoid arthritis (PR) has increased in recent years. In addition, If the extra-articular manifestations have become rare in the era of modern. Nevertheless, targeted treatments, they are nonetheless a challenge, just like the Rheumatoid nodules. In addition to the difficulties linked to differential diagnosis. Consequently, possible complications – especially when they are located in the lungs – these recurrent inflammatory granulomes pose a not only aesthetic problem for many people, but sometimes also functional.

On the occasion of EULAR 2025 congress (European Alliance of Associations for Rheumatology). Furthermore, the Pr Christopher Edwardsrheumatologist at the Southampton University Hospital (United Kingdom), explained what the rheumatoid nodules are and how to take care of them ^[1].

Rheumatoid nodules: what is it?

“At the start of my career, the Rheumatoid nodules still constituted a diagnostic criterion of PR,” he started. For example, rheumatoid nodules: new recommendations If we did not already find it on the hands. Meanwhile, we systematically examine the elbows, the Achilles tendons being also a favorite site. In addition, The rheumatoid nodules. However, which are histologically a granulomatous inflammation evolving by stages, are not only located under the skin but also in the sclera, larynx, cardiac valves and, above all, lungs.

A biopsie in case of tumor suspicion

These different possible locations can pose a differential diagnostic problem. Consequently, “I saw patients who had been said to have pulmonary metastases,” recalls the rheumatologist. However, What generate a lot of anxieties before an additional imaging examination and a biopsy is carried out.

The distinction with infections (especially tuberculosis) is particularly important. Moreover, PR and immuno-modulator treatments expose patients more strongly to infections. In addition. In addition, just like tuberculomers, pulmonary rheumatoid nodules can be necrotic under the effect of TNF-α inhibitors, which rheumatoid nodules: new recommendations can lead to a crying (cave) or even pneumothorax involvement. Additionally, In addition, At this point, they become problematic. “Any pulmonary cave can be infected. Furthermore, »»

The biopsy of a rheumatoid nodule is only very rarely necessary Pr Christopher Edwards

Rubber consistency

On the outskirts. the diagnosis is generally quite simple, according to the rheumatologist. Typically, the nodules have a rubber consistency in palpation and are mobile compared to the underlying tissues. The main differential diagnoses for subcutaneous rheumatoid nodules are above all gouty tophus. as well as lipomas, epidermoid cysts, infectious granulomas, sarcoidosis and various tumors.

Imaging, ultrasound or puncture in case of suspected gout can be useful. “A biopsy is only very rarely necessary. namely when the nodule is in a place that can be suspected a neoplastic process,” said Professor Edwards.

Fewer nodules thanks to good disease control

“Today, rheumatoid nodules: new recommendations I see very few nodules in my clinical practice,” adds the specialist. Epidemiological data also confirms that the risk of developing rheumatoid nodules in PR patients has halved since the early 2000s.

Several factors have probably contributed to it: above all earlier. more effective and more rigorous treatments, but also a decrease in smoking, which is a significant risk factor as well as male sex, the presence of rheumatoid factor (FR) or anti-cyclical anti-peptids (anti-CCP). “Patients are practically always HIV positive. »»

The control of the activity of the disease therefore seems more decisive for the prevention of rheumatoid nodules. than the potential trigger role of certain drugs.

Rarely a reason to stop methotrexate

“We were concerned about the fact that methotrexate (MTX) could be involved. ” said Professor Edwards. The nodules sometimes seemed to appear more frequently in patients treated with this medication. “But today we use rheumatoid nodules: new recommendations more MTX, and there are fewer rheumatoid nodules. »»

There is something. in terms of the skin of the elbow and the olecranian scholarship, which makes that many infections develop there Pr edwards

“Overall, I think that the presence of nodules does not justify the end of methotrexate. This was not the case at the time, and it is still not today. On the other hand, one could sometimes consider a more aggressive treatment. »»

The appearance of rheumatoid nodules has also been reported under other substances, including anti-TNFs, and in particular the spa. Professor Edwards thinks that there must be a factor of confusion. and that this type of treatment may not be the cause.

An intervention is not always necessary. “Sometimes you just have to be content to observe. When a nodule is painful and annoying, a local injection of glucocorticoids can soften it and rheumatoid nodules: new recommendations alleviate the symptomatology. The rheumatologist, however, claims to have never practiced infiltration himself and he recommends prudence, especially at the elbow. “There is something. in terms of the skin of the elbow and the olecrenian purse, which makes many infections develop there. I saw a patient having to consult a plastic surgeon because of a crevasse left by an infection. To this is added another characteristic of the rheumatoid nodules, which is the tendency to recur.

No new nodule appears in a patient treated with RTX Pr edwards

When to operate?

“Some people can benefit from surgery,” said Christopher Edwards. Indications of a rare – surgical removal are complications such as ulcers. infections, or when a large nodule at the end of the index or thumb prevents from grasping objects. “These patients are happy to find this function, even if the nodule reappears two years rheumatoid nodules: new recommendations later. The same goes for areas subject to frequent friction in the shoes or by the suspenders of certain clothes.

The pulmonary rheumatoid nodules. which also contain B cells unlike subcutaneous nodules, generally respond well to treatment with Rituximab (RTX) or by slaughter. “They tend to improve or regress under RTX. And it is certain that no new nodule appears in a patient treated by RTX. In addition. improvements have also been reported in clinical cases and series of cases dealt with by a inhibitor of Janus Kinase (Jaki).

This article has been translated and adapted from Medscape.de

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