Bywaters lesion is a cutaneous vasculitis seen in rheumatoid arthritis.1
A 70-year-old man presenting with polyarthritis and finger papules visited our hospital. The patient had a 12-year history of polyarthritis, and bilateral ulnar deviation developed 5 years prior. Computed tomography indicated interstitial pneumonia, and blood work confirmed a rheumatoid factor level of 2708 (normal < 15) IU/mL and anticyclic citrullinated peptide antibody level of 114.5 (normal < 4.5) U/mL. He was diagnosed with rheumatoid arthritis and prescribed prednisolone (10 mg PO/day), sulfasalazine (1 g PO/day), and iguratimod (50 mg PO/day).
His condition improved significantly over 2 years, following treatment with abatacept. Prednisolone had been gradually tapered and stopped 6 months prior. Subsequently, the arthritis worsened; however, he did not wish to resume taking oral steroids. Therefore, intraarticular glucocorticoid injections were administered for chronic inflammation.
During a recent visit, we observed new-onset papules on the fingers and around the edges of the fingernails (Figure 1). Dermatoscopy revealed thrombosis and telangiectasia in the nail folds (Figure 2) without other systemic vasculitis symptoms.
The appearance of new-onset papules on the fingers and nail edges.
Dermatoscopy revealed thrombosis and telangiectasia in the nail folds.
The symptoms of Bywaters lesions include purple papules around nails and digital pulp, which may progress to larger papules and hemorrhaging lesions, increasing the risk of infarction around the nail folds.2 Systemic vasculitis complications are rare, but patients with rheumatic nodules and high rheumatoid factor titers are at risk of rheumatoid vasculitis,3 as was the case in our patient. We could not identify other published dermatoscopic images of Bywaters lesions in the literature. After a 7-day course of prednisolone (≤ 60 mg/day), the papules and polyarthritis resolved.
Footnotes
The authors declare no conflicts of interest relevant to this article. The need for ethics approval was waived due to the nature of this study. Informed written consent was obtained from the patient.
- Copyright © 2023 by the Journal of Rheumatology
