A cutaneous-only variant of rheumatoid vasculitis with symmetric flexural pyoderma gangrenosum-like lesions

Rheumatoid vasculitis, an uncommon extraarticular manifestation of rheumatoid arthritis, usually develops in long-standing cases affecting small-to-medium-sized vessels. It is a poor prognostic marker when multiple systems are affected, skin and neurologic involvement being most frequent. Rheumatoid vasculitis is seen more commonly in seropositive and nodular rheumatoid arthritis patients who are male or smoke. Herein, we present the peculiar case of a 48-year-old female with rapid onset, progressive, multiple ulcers predominantly over the flexures. Differential diagnoses of pyoderma gangrenosum, pyoderma vegetans, pemphigus vegetans, and vasculitis were considered, and the patient was evaluated. On investigation, her rheumatoid factor titer was strongly positive; a skin biopsy revealed leukocytoclastic vasculitis. On clinical, serological, and histopathological correlation, a diagnosis of rheumatoid vasculitis was made, responding well to high-dose prednisolone. On follow-up at six months, her skin lesions had healed well with moderate scarring; however, she developed severe joint pain, warranting the initiation of disease-modifying antirheumatic drugs. To the best of our knowledge, this is a previously unreported clinical and morphological presentation of rheumatoid vasculitis.