Case Study in Dermatology: Tender Papules on Elbows, Hands in RA

Although the distribution may resemble PNGD, the histopathologic features characteristically lack a granulomatous infiltrate. Instead, lesions demonstrate dense neutrophilic inflammation and almost invariably exhibit leukocytoclastic vasculitis. EED may occur in the setting of an associated disorder, most often HIV, an IgA mono­clonal gammopathy, or a hematologic malignancy. It is usually not associated with an autoimmune or connective tissue disease.

Drew Kurtzman, MD, is a clinical fellow in Dermatology-Rheumatology, Department of Dermatology at Brigham and Women’s Hospital, Harvard Medical School, Boston.

Timothy McCalmont, MD, is co-director, Dermatopathology and Oral Pathology, at the University of California, San Francisco, and professor, Pathology and Dermatology, University of California, San Francisco.

Ruth Ann Vleugels, MD, MPH, is director, Autoimmune Skin Diseases Program, director, Connective Tissue Disease Clinics, program director, Dermatology-Rheumatology Fellowship Program and associate director, Education, in the Department of Dermatology, Brigham and Women’s Hospital, Boston, and assistant professor, Harvard Medical School, Boston.

Joseph F. Merola, MD, MMSc, is a dermatologist and rheumatologist, an assistant professor at Harvard Medical School, the director of clinical trials and co-director of the Center for Skin and Related Musculoskeletal Diseases at Brigham and Women’s Hospital in Boston.

References

1. Chu P, Connolly MK, LeBoit PE. The histopathologic spectrum of palisaded neutrophilic and granulomatous dermatitis in patients with collagen vascular disease. Arch Dermatol. 1994 Oct;130(10):1278–1283.
2. Rosenbach M, English JC 3rd. Reactive granulomatous dermatitis: A review of palisaded neutrophilic and granulomatous dermatitis, interstitial granulomatous dermatitis, interstitial granulomatous drug reaction, and a proposed reclassification. Dermatol Clin. 2015 Jul;33(3):373–387.
3. Hantash BM, Chiang D, Kohler S, Fiorentino D. Palisaded neutrophilic and granulomatous dermatitis associated with limited systemic sclerosis. J Am Acad Dermatol. 2008;58(4):661–664.
4. Stephenson SR, Campbell SM, Drew GS, Magro CM. Palisaded neutrophilic and granulomatous dermatitis presenting in a patient with rheumatoid arthritis on adalimumab. J Cutan Pathol. 2011 Aug;38(8):644–648.
5. Misago N, Shinoda Y, Tago M, Narisawa Y. Palisaded neutrophilic granulomatous dermatitis with leukocytoclastic vasculitis in a patient without any underlying systemic disease detected to date. J Cutan Pathol. 2010 Oct;37(10):1092–1097.
6. Fett N, Kovarik C, Bennett D. Palisaded neutrophilic granulomatous dermatitis without a definable underlying disorder treated with dapsone. J Am Acad Dermatol. 2011 Sep;65(3):e92–e93.