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Rheumatoid nodules

John M Davis, MD, MS
Section Editor
James R O'Dell, MD
Deputy Editor
Paul L Romain, MD


The rheumatoid nodule is the most common cutaneous manifestation of rheumatoid arthritis (RA) [1,2]. Although nodules commonly are found on pressure points (such as the olecranon process), they may occur at other sites, including ones within internal organs of the body. Thus, bedridden patients can develop nodules on the occiput and ischial areas, and nodules occasionally form on the Achilles tendon and vocal cords [3]. Rheumatoid "nodulosis" is characterized by multiple nodules on the hands and multiple subchondral bone cysts known as "geodes" [4]. These nodules tend to occur on extensor surfaces adjacent to joints, elbows, and fingers, as well as the forearm, metacarpophalangeal and proximal interphalangeal joints, occiput, back, heel, and other areas [5].

The clinical and histopathologic features, diagnosis, and treatment of rheumatoid nodules will be reviewed here. The articular features and an overview of the systemic and nonarticular manifestations of RA are presented separately. (See "Clinical manifestations of rheumatoid arthritis" and "Overview of the systemic and nonarticular manifestations of rheumatoid arthritis".)


Subcutaneous rheumatoid nodules — Palpable nodules in the subcutaneous tissues have been reported at initial presentation in 7 percent of patients with rheumatoid arthritis (RA) [6] and are found at some time during the disease course in 30 to 40 percent of patients [7]. In Rochester, Minnesota, the cumulative incidence of rheumatoid nodules remained unchanged between 1985 and 1994 and 1995 and 2007 at 31 percent [8]. Further research is needed to determine the impact of evolving treatment strategies on the incidence of rheumatoid nodules in patients with early RA. The vast majority of nodule-formers have positive tests for rheumatoid factor [1]. Nodules are found in 75 percent of patients with RA-associated Felty's syndrome [5]. (See "Clinical manifestations and diagnosis of Felty's syndrome".)

RA patients with nodules are also more likely to develop vasculitis [9]. Limited data suggest that many patients with rheumatoid nodules have positive tests for antibodies to citrullinated proteins (ACPA) [10]. In general, patients with rheumatoid nodules tend to have a severe RA phenotype, with more rapid progression of joint destruction than other patients with RA [11]. Rheumatoid nodules have also been noted in occasional patients with systemic lupus erythematosus, ankylosing spondylitis, granuloma annulare, and chronic active hepatitis, and have been found infrequently in healthy children and adults [5]. An association of rheumatoid nodules in RA with the presence of antiphospholipid antibodies has also been reported [12]. Patients with rheumatoid nodules are also at greater risk of hospitalization [13] due to complications of their disease or comorbidities and to experience lower extremity ulcers, which are associated with significant morbidity related to soft tissue, bone, and joint infections [14].

The size of the nodules varies from 2 mm to 5 cm; they are firm, nontender, and moveable in subcutaneous tissue (picture 1) [5].

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Literature review current through: Nov 2017. | This topic last updated: Aug 08, 2017.
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