Skin Manifestations in

Rheumatic Diseases
Samar
Tharwat
Lecturer of Internal Medicine
(Rheumatology &
Immunology)
Mansoura University
AGENDA

✗ Presentation of Skin Manifestations

✗ Inflammatory Joint Diseases

✗ Connective Tissue Diseases

✗ Vasculitides

✗ Methodology

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Presentation of Skin
Manifestations
Malar erythema
Purpura
Livedo reticularis
Telangectasia
Ulceration
Panniculitis
Puffy fingers
Rosacea

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Livedo Reticularis
✗ Mottled, reticulated vascular pattern

✗ Due to alterations in blood flow

through the cutaneous

microvasculature

✗ AE: physiologic, rheumatic

disease
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 Purpura

Macular petechiae Macular ecchymoses Palpable purpura

(corticosteroid, amyloidosis) (leukocytoclastic vasculitis)
(thrombocytopenia)

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 Telangiectasias

• Dilatation of the capillaries, arterioles,

and/or venules
• Erythematous
• Blanchable
• Anywhere on the skin & mucous
membranes
• Cosmetic
• May be primary as Hereditary hemorrhagic
telangiectasia
• Or secondary

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 Secondary Telangiectasias

subacute cutaneous Postinflammatory Telangiectatic and avascular

erythematosus telangiectasia in a patient patches typical of
dermatomyositis
with dermatomyositis

Matted telangiectasias of Telangiectasias on PIPJ in a Typical periungual

systemic sclerosis patient with systemic telangiectasias in this
sclerosis patient with SLE

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 Ulceration in Rheumatic Diseases

Aphthous ulcer on the lower lip pyoderma gangrenosum

shows a fibrinous base (Behçet’s with an Lupus ulcer Systemic sclerosis
disease) undermined ulcer
(Behçet’s disease

ulceration on the digit pulp and the Left leg with ulcers in a patient with
lateral erythema ( Dermatomyositis) rheumatoid arthritis Ulcers in vasculitis

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Panniculitis
Inflammation of the SC adipose tissue
Associations:
✗ infections
✗ oral contraceptives
✗ antibiotics
✗ Sarcoidosis
✗ Behçet’s disease
✗ SLE
✗ Crohn’s disease
✗ primary biliary cirrhosis
✗ idiopathic

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 Puffy Fingers
No clear definition
Differential Diagnosis
✗ Systemic Sclerosis
✗ limited cutaneous SSc with ACA
✗ limited cutaneous SSc with Anti-Th/To Antibody
✗ Early SSc with Anti-Topoisomerase I Antibody
✗ Sclerodactyly in dcSSc with Anti-RNA
Polymerase Antibody
✗ Mixed connective tissue disease
✗ SSc-Like Disorders
✗ Anti Synthetase Antibody Syndrome
✗ Rheumatoid Arthritis
✗ Overlapping Syndromes

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 Skin in Rheumatic
Diseases

• Inflammatory Joint
Diseases
• Connective Tissue
Diseases
• Vasculitides
 Nodules in Rheumatoid Arthritis
• 1 in 4 patients with long-standing RA will have rheumatoid
nodules
• Seropositive disease
• Non-tender, firm , extensor surfaces
• Benign nodules: rheumatoid nodules in the absence of RA

Palisaded neutrophilic
Rheumatoid nodules & granulomatous dermatitis

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 Psoriasis and Psoriatic Arthritis

Psoriatic plaques Guttate psoriasis Inverse psoriasis Sebopsoriasis

Erythrodermic Pustular psoriasis Psoriatic nail with

psoriasis onycholysis, pitting
and discoloration

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 Inflammatory Bowel-Associated
Spondyloarthropathy

Erythema nodosum Pyoderma Pyostomatitis

gangrenosum vegetans

Cutaneous Metastatic Crohn’s Sweet’s syndrome

polyarteritis nodosa

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 Reactive Arthritis

Circinate balanitis Erosions on tongue Nail changes Keratoderma

include nail dystrophy, Blennorrhagica
subungual debris, and
periungual pustules

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 Rheumatic Fever

Erythema Subcutaneous
marginatum nodules
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Skin Manifestations of Juvenile Idiopathic Arthritis

Maculopapular Nail pitting in PsA

rash of sJIA

Dactylitis in PsA The classic lesions

of psoriasis

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 Skin in Rheumatic
Diseases

• Inflammatory Joint
Diseases
• Connective Tissue
Diseases
• Vasculitides
 Systemic Lupus Erythematosus
✗ ✗ Subacu ✗ Chronic Lupus non specific
Acute te

Discoid LE

Butterfly rash Oral ulcers Annular type Raynaud’s Livedo reticularis

phenomenon

lupus
panniculitis

Photosensitivity Psoriasiform
Leukocytoclastic
LE tumidus vasculitis

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 Neonatal Lupus Erythematosus

Periorbital and inguinal distribution pattern of skin lesions of neonatal SCLE in a 2-

month- old female baby ( left ). The sternal scar results from the implantation of a
cardiac pacemaker for atrioventricular block grade III

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 Systemic Sclerosis

Skin sclerosis Skin sclerosis (and Expressionless face Diffuse hyperpigmentation

hyperpigmentation) of hypopigmentation
trunk

Salt and pepper pattern Furrowing of the mouth Extensive subcutaneous

calcinosis

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 Localized Scleroderma
✗ Limited type ✗ Generalized type ✗ Linear type

Linear localized
scleroderma

Generalized localized
Morphea scleroderma (3 or more
anatomic sites)

En coup de
sabre

Disabling pansclerotic
Guttate morphea Parry Romberg
morphea syndrome

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 Dermatomyositis

Gottron’s papules Gottron’s papule Heliotrope rash and

periorbital edema

V sign Periungual
telangiectasia

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 Sjögren’s Syndrome

Xerosis Angular Erythema Vasculitis Urticarial

Cheilitis annulare vasculitis

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 Skin in Rheumatic
Diseases

• Inflammatory Joint
Diseases
• Connective Tissue
Diseases
• Vasculitides
 Giant Cell Arteritis

Scalp necrosis with loss of Ischemic Two months after treatment. visible temporal artery
surrounding hair necrosis of tongue There has been sloughing thickening or nodularityand
of skin of tip of tongue and erythema over the superfi cial
healing temporal arteries

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 Kawasaki Disease

Macular, Strawberry tongue Edema of dorsum

morbilliform rash of both hands

Palmar erythema Peeling, exfoliation

of hands

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 Granulomatosis with Polyangiitis
(Wegener’s Granulomatosis)

Necrotic Papulonecrotic Livedo Necrotic

purpura lesions reticularis lesions

Gangrene Oral ulcers Gingivitis Xanthelasmas

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 Henoch-Schönlein Purpura

Palpable purpura palpable purpura involving Typical palpable purpura

the upper and lower on the buttocks

Ecchymoses and purpura of Bullous evolution of

the scrotum; the penis is purpuric lesions
swollen and ecchymotic

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 Behçet’s Disease

Oral ulcers Genital ulcers Erythema nodosum

Superficial thrombophlebitis Pathergy Reaction

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Methodology
Capillaroscopy
Skin Biopsy
 Capillaroscopy

Secondary Raynaud’s The three scleroderma patters

phenomenon ( early , active , late )

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 Skin Biopsy
✗ Site Selection: Anatomical Region, Type of
Lesion
✗ Indications:
Rheumatoid Arthritis
Lupus Erythematosus (LE)
Scleroderma
Dermatomyositis
Psoriasis with Psoriatic
Arthritis
Vasculitis
Panniculitis
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