Rheumatoid arthritis (RA) is a chronic autoimmune condition that predominantly affects the joints, causing inflammation, pain, and progressive joint damage. Among the many manifestations of RA, rheumatoid nodules are one of the most recognisable extra-articular (outside the joints) symptoms.

These nodules occur in approximately 20% to 30% of people with RA, particularly those with severe disease or those who are positive for rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP) antibodies. Understanding the symptoms, causes, and implications of rheumatoid nodules is essential for early diagnosis, effective management, and improving patient outcomes.
What Are Rheumatoid Nodules?
Rheumatoid nodules are firm, subcutaneous lumps that typically develop beneath the skin. These nodules are primarily composed of inflammatory tissue and collagen, resulting from the autoimmune processes underlying RA. They are most commonly found in areas subject to pressure or repetitive trauma, such as the elbows, fingers, and forearms. However, they can also form in other locations, including internal organs.
Although rheumatoid nodules are usually asymptomatic and do not cause pain, they can occasionally lead to complications, particularly if they interfere with movement, press against nerves, or become infected. In some cases, these nodules may be the first noticeable symptom of RA, even before joint pain or swelling appears.
Symptoms Of Rheumatoid Nodules
The symptoms associated with rheumatoid nodules vary depending on their size, location, and the extent of tissue involvement. Below is a detailed explanation of the common symptoms and potential complications.
Physical Appearance And Texture
Rheumatoid nodules are typically:
- Firm to the touch: Unlike cysts or lipomas, which may feel soft or fluctuant, rheumatoid nodules have a rubbery or hard consistency.
- Well-defined: The borders of the nodules are usually distinct, making them easy to differentiate from surrounding tissues.
- Round or oval-shaped: They often appear as small lumps, though larger or irregular nodules can occur in severe cases.
- Size variability: Nodules can range from a few millimetres to several centimetres in diameter. Larger nodules are more likely to cause discomfort or complications.
Common Locations
Rheumatoid nodules are most frequently located in areas subject to frequent pressure or mechanical stress. Common sites include:
- Elbows: This is the most prevalent location, as elbows often rest against hard surfaces.
- Fingers and knuckles: Nodules in these areas can interfere with hand movement and dexterity.
- Forearms and wrists: These are additional common sites for nodule formation.
- Other pressure points: Knees, heels, and the back of the head (occiput) are less common but possible locations.
Pain And Discomfort
Most rheumatoid nodules are painless. However, certain factors may lead to discomfort:
- Pressure sensitivity: Nodules in weight-bearing areas or places subject to repeated trauma can become tender or sore.
- Infection: If a nodule becomes infected, it may become red, warm, and painful.
- Compression of nerves or tissues: In rare cases, large nodules may press against nerves, causing localised pain, numbness, or tingling.
Skin Changes
Overlying skin may exhibit changes due to the presence of a rheumatoid nodule. These changes include:
- Thinning of the skin: Chronic pressure from the nodule can lead to atrophy of the skin.
- Ulceration: In severe cases, the skin over a nodule may break down, resulting in open sores that are prone to infection.
- Discolouration: Infected or inflamed nodules may cause the overlying skin to appear red or bruised.
Complications With Movement
Large or strategically located nodules can impede mobility by:
- Restricting the joint range of motion: Nodules near joints can obstruct normal movement.
- Interfering with daily activities: Nodules on the hands or feet may make tasks like writing, typing, or walking difficult.
Systemic Symptoms
In rare cases, rheumatoid nodules can form internally, affecting organs such as the lungs, heart, or vocal cords. Symptoms of internal rheumatoid nodules include:
- Respiratory issues: Nodules in the lungs may cause coughing, shortness of breath, or chest pain.
- Hoarseness: Vocal cord nodules can affect speech.
- Cardiac complications: Nodules on the heart valves may lead to heart murmurs or other symptoms.
Causes And Risk Factors
The exact cause of rheumatoid nodule formation remains unclear, but several factors are believed to contribute:
- Autoimmune Inflammation: RA triggers an overactive immune response, leading to chronic inflammation that promotes the development of nodules.
- Rheumatoid Factor (RF): Patients who test positive for RF or anti-CCP antibodies are at higher risk of developing nodules.
- Disease Severity: Nodules are more common in individuals with severe or longstanding RA.
- Medication Side Effects: Certain RA treatments, such as methotrexate, can paradoxically increase the risk of nodules in some individuals.
- Lifestyle Factors: Smoking and repetitive trauma to specific areas may exacerbate the likelihood of nodule formation.
Diagnosis
Diagnosing rheumatoid nodules typically involves a combination of clinical examination, medical history, and diagnostic tests:
- Physical Examination: Doctors assess the size, location, and consistency of the nodules.
- Imaging: X-rays, ultrasound, or MRI scans may be used to evaluate internal nodules or rule out other conditions.
- Biopsy: In rare cases, a biopsy of the nodule may be performed to confirm the diagnosis and exclude other causes, such as malignancy or infection.
Treatment And Management
While many rheumatoid nodules do not require treatment, intervention may be necessary if the nodules cause significant discomfort, interfere with function, or lead to complications. Treatment options include:
Medication Adjustments:
- Disease-Modifying Anti-Rheumatic Drugs (DMARDs): Modifying or intensifying RA treatment can help control overall disease activity and reduce nodule formation.
- Corticosteroid Injections: Localised injections may reduce inflammation and shrink nodules temporarily.
Surgical Removal:
- Nodules causing severe pain, ulceration, or interference with mobility may be surgically excised. However, recurrence is possible.
Lifestyle Modifications:
- Avoiding repetitive trauma to affected areas and using protective padding can minimise discomfort.
- Smoking cessation is strongly recommended, as smoking is associated with worse RA outcomes and increased nodule formation.
Treatment Of Infections:
- Infected nodules require prompt medical attention, including antibiotics and possible drainage.
Prognosis
The prognosis for individuals with rheumatoid nodules largely depends on the overall management of their RA. Effective control of disease activity through medication, lifestyle changes, and regular medical follow-ups can minimise complications. While nodules may persist or recur, maintaining low disease activity significantly reduces their impact on quality of life.
Conclusion
Rheumatoid nodules are a common extra-articular manifestation of rheumatoid arthritis, particularly in individuals with severe disease or seropositivity. Although often asymptomatic, these nodules can cause physical, functional, and systemic complications, particularly when left untreated.
Early recognition, appropriate management, and proactive measures to control RA activity are key to preventing the progression and complications associated with rheumatoid nodules. Patients experiencing new or worsening symptoms should consult their healthcare provider promptly for tailored advice and intervention.
Frequently Ask Question
What Are Rheumatoid Nodules, And Where Do They Commonly Occur?
Rheumatoid nodules are firm lumps that develop beneath the skin in individuals with rheumatoid arthritis (RA). They are composed of inflammatory tissue and collagen and typically appear in areas subject to pressure, such as the elbows, fingers, forearms, and knees. In some cases, nodules can also form in internal organs like the lungs or heart.
Are Rheumatoid Nodules Painful?
Most rheumatoid nodules are painless. However, they can become tender if located in weight-bearing areas, subjected to frequent trauma, or if they become infected. In rare cases, large nodules may press against nerves, causing pain, numbness, or tingling.
What Causes Rheumatoid Nodules To Form?
The exact cause of rheumatoid nodule formation is unclear, but chronic autoimmune inflammation in RA plays a significant role. Factors such as the presence of rheumatoid factor (RF), severe disease, certain medications like methotrexate, smoking, and repetitive trauma to specific areas increase the likelihood of developing nodules.
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