1. Wounds in Rheumatic Diseases
2017 TOWN HALL

2. Learning Objectives
Recognize systemic features of rheumatic diseases causing skin wounds
Identify patterns of skin lesions in rheumatic diseases
Labs, treatment will NOT be discussed

3. Overview Crystal-associated skin lesions
Monosodium urate crystals: gout
Calcium crystals: scleroderma, dermatomyositis
Vascular disease – arterial insufficiency
Vasculitis: small, medium-sized arteries
Vasculopathy may affect any size of arteries

4. Gout
A disease caused by monosodium urate crystal saturation of tissues over time due to high blood levels of uric acid
More common in men – post-puberty decrease in renal clearance of uric acid
Women can develop gout, but usually 15-20y after menopause
NO SYSTEMIC FEATURES

5. Clinical Features of Gout
Intermittent acute mono-arthritis
Tophi are crystalline joint and superficial subcutaneous deposits that occur years of hyperuricemia
These may erode through the skin and cause wounds draining MSU crystals

7. Gout: clinical manifestations
Peripheral joints, one at a time
Lower extremity attack precedes upper extremity
Attack lasts 7-10 d.
Desquamation is typical

8. Management of Acute Gout
Control joint inflammation
Options:
Joint drainage and intraarticular steroid
NSAIDs
Colchicine
IV or oral steroids

9. Tophi Rx Background control of inflammation, THEN… Add a med to reduce uric acid

10. Tophaceous Gout:

11. Longterm Prognosis Requires years to mobilize tophaceous uric acid stores Residual joint pain if erosions are present

12. Calcinosis This is a feature of an underlying autoimmune disease.
Associated conditions: scleroderma, dermatomyositis
The calcium crystal deposits can irritate the overlying skin, cause a sterile cellulitis, and spontaneously drain. This can be therapeutic.
Other treatment options: colchicine, steroids

14. Juvenile Dermatomyositis
Dramatic calcinosis

15. Diffuse Scleroderma Skin thickening, tightening Vasculopathy

16. Limited Scleroderma
Vasculopathy + Raynaud can cause painful digital ischemia, gangrene
Treatment: vasodilators, sympathectomy

17. Vasculitis Inflammation of the blood vessel walls
If CUTANEOUS vasculitis, can compromise blood flow to the skin and cause skin lesions – rash, ulceration.
Exam, labs and skin biopsy help to determine the size of vessel involved

18. Vasculitis classification
Based on clinical presentation, +/- labs
Once ulcerated, may be very tough to tell!
Biopsy can be necessary

19. Nonblanching rash Petechiae: <3mm Purpura are larger,
often palpable
Typically result from
hemorrhage due to
trauma or vasculitis
35 yo with small vessel vasculitis due to an antibiotic. Palpable purpura, lesions sting and burn, surrounding edema.
Biopsy: LCV
Diseases that can cause this: many autoimmune diseases, including lupus and Sjogren syndrome

20. Leukocytoclastic Vasculitis (LCV)
Inflammation of small artery walls with
Yellow arrows: cellular debris
Black arrows: fibrin thrombi

21. LCV
Small vessels
May be idiopathic or due to underlying disease, often autoimmune such as SLE or ANCA vasculitis; r/o drug reaction
Burning/stinging lesions w surrounding edema; may ulcerate
Treatment: steroids, colchicine

22. LCV with complications
Obese RN with LCV,
Foot drop due to SLE
Rx prednisone 60 mg daily
with slow taper
50 lb wt gain, T2DM, LE edema
Nonhealing ulceration
Obese 55 yo lady with T2DM complicated by peripheral neuropathy, biopsy proven small vessel cutaneous vasculitis (LCV) 3 years prior, on Dapsone 100 mg daily and prednisone 15 mg twice a day with pitting edema to knees and a painless 6 x4.5 cm ulcer, clean base.no surrounding erythema. Gained >50 lb on steroids over past 3 years.
Typically painful, but this is painless due to neuropathy
Resolved with steroid titration and management of EDEMA

23. Systemic or skin only?
Fever, chills, sweats, loss of appetite
Raynaud
Alopecia, malar rash
Joint pain

24. Lupus
Young women, 9:1
Raynaud
Alopecia
Photosensitive rash

25. Lupus: alopecia

26. Lupus: Internal Organs
Pericarditis, pleurisy
Glomerulonephritis, renal failure
CNS: seizures, CVA, meningitis
APL: thromboembolic events
Premature coronary artery disease
Increased mortality: infection, CAD