Skip to main content

Advertisement

SpringerLink
Log in

Lower extremity ulcers in rheumatoid arthritis: features and response to immunosuppression

  • Brief Report
  • Published:
Clinical Rheumatology Aims and scope Submit manuscript

Abstract

Lower extremity ulcers are a recognized complication of rheumatoid arthritis (RA). Their prevalence has not been assessed since the advent of more aggressive disease modifying antirheumatic therapies. The purpose of this study was to establish the period prevalence of lower extremity ulcers in a modern-day unselected cohort of patients with RA, and to report the features associated with ulcer development and response to therapy. Between June 2007 and June 2010, 366 RA patients were evaluated at the Georgetown Division of Rheumatology. Data were collected and analyzed retrospectively on demographics, antibody and prothrombotic profile, comorbidities, disease activity, and outcomes. The period prevalence of ulcers in this cohort of 366 patients with RA followed over 3 years was 4.37%. Patients with ulcers were predominantly female (81.25%) and more commonly African American (56.2%). The mean disease duration at ulcer development was 25.9 years. All patients with ulcers had erosive disease and 63% were seropositive. Only five patients (31.25%) healed over a mean follow-up of 22.8 months. However, in this small sample, treatment with anti-tumor necrosis factor-α (anti-TNFα) therapy was associated with significantly higher likelihood of healing (p = 0.039). In this modern-day cohort of patients with RA, we found a prevalence of lower extremity ulcers of 4.37% over 3 years. Only 31.25% of patients healed after a mean 22.8 months of follow-up. However, treatment with a biologic agent was associated with a significant increased likelihood of healing (RR 3.27, 95% CI 0.59-18.29, p = 0.039).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Pun YL, Barraclough DR, Muirden KD (1990) Leg ulcers in rheumatoid arthritis. Med J Aust 153(10):585–587

    PubMed  CAS  Google Scholar 

  2. Oien RF, Hakansson A, Hansen BU (2001) Leg ulcers in patients with rheumatoid arthritis—a prospective study of aetiology, wound healing and pain reduction after pinch grafting. Rheumatology 40(7):816–820

    Article  PubMed  CAS  Google Scholar 

  3. Nishikawa JA (1983) Are leg ulcers in rheumatoid arthritis due to vasculitis? Eur J Rheumatol Inflamm 6(3):288–290

    PubMed  CAS  Google Scholar 

  4. Cawley MID (1987) Vasculitis and ulceration in rheumatic diseases of the foot. Baillières Clin Rheumatol 1(2):315–333

    Article  PubMed  CAS  Google Scholar 

  5. McRorie ER, Ruckley CV, Nuki G (1998) The relevance of large-vessel vascular disease and restricted ankle movement to the aetiology of leg ulceration in rheumatoid arthritis. Br J Rheumatol 37(12):1295–1298

    Article  PubMed  CAS  Google Scholar 

  6. Hafner J, Schneider E, Burg G, Cassina PC (2001) Management of leg ulcers in patients with rheumatoid arthritis or systemic sclerosis: the importance of concomitant arterial and venous disease. J Vasc Surg 32(2):322–329

    Article  Google Scholar 

  7. Thurtle O, Cawley M (1983) The frequency of leg ulceration in rheumatoid arthritis: a survey. J Rheumatol 10(3):507–509

    PubMed  CAS  Google Scholar 

  8. Firth J, Hale C, Helliwell P, Hill J, Nelson EA (2008) The prevalence of foot ulceration in patients with rheumatoid arthritis. Arthritis Care Res 59(2):200–205

    Article  Google Scholar 

  9. McRorie E (2000) The assessment and management of leg ulcers in rheumatoid arthritis. J Wound Care 9(6):289–292

    PubMed  CAS  Google Scholar 

  10. Watts RA, Mooney J, Lane SE, Scott DGI (2004) Rheumatoid vasculitis: becoming extinct? Rheumatology 43(7):920–923

    Article  PubMed  CAS  Google Scholar 

  11. Charabaty S, Shanmugam V (2009) A 65-year-old man with longstanding seropositive rheumatoid arthritis and lower extremity ulceration. Arthritis Care Res 61(9):1275–1280

    Article  Google Scholar 

  12. Shanmugam V, Steen V, Cupps T (2008) Lower extremity ulcers in connective tissue disease. Isr Med Assoc J 10(7):534–536

    PubMed  Google Scholar 

  13. Shanmugam V, Price P, Attinger C, Steen V (2010) Lower extremity ulcers in systemic sclerosis: features and response to therapy. Int J Rheumatol. doi:10.1155/2010/747946

  14. National Collaborating Center for Chronic Conditions (2009) Rheumatoid arthritis: national clinical guideline for management and treatment in adults. Royal College of Physicians, February 2009

  15. Dixon WG, Watson K, Lunt M, Hyrich KL, Silman AJ, Symmons DPM (2006) Rates of serious infection, including site-specific and bacterial intracellular infection, in rheumatoid arthritis patients receiving anti-tumor necrosis factor therapy: results from the British Society for Rheumatology Biologics Register. Arthritis Rheum 54(8):2368–2376

    Article  PubMed  CAS  Google Scholar 

  16. Sheehan P, Jones P, Caselli A, Giurini JM, Veves A (2003) Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diab Care 26(6):1879–1882

    Article  Google Scholar 

  17. Unger L, Kayser M, Nusslein HG (2003) Successful treatment of severe rheumatoid vasculitis by infliximab. Ann Rheum Dis 62(6):587–588

    Article  PubMed  CAS  Google Scholar 

  18. Matthews C, Fitzgerald O (2006) Seropositive erosive rheumatoid arthritis (RA). Rheumatology 45(9):1100

    Article  PubMed  CAS  Google Scholar 

  19. Hirche D, Rubbert A, Lunau L, Krieg T, Eming SA (2005) Successful treatment of refractory rheumatoid arthritis-associated leg ulcerations with adalimumab. Br J Dermatol 152(5):1062–1064

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

This work was supported by the Physician Scientist Development Award from the American College of Rheumatology Research and Education Foundation and by award numbers KL2RR031974 and UL1RR031975 from the National Center for Research Resources.

Disclosures

None.

Author information

Authors and Affiliations

  1. Division of Rheumatology, Immunology and Allergy, Georgetown University Hospital, 3800 Reservoir Road, NW Washington, DC, 20007, USA

    Victoria K. Shanmugam & David M. DeMaria

  2. Center for Wound Healing, Georgetown University Hospital, 3800 Reservoir Road, NW Washington, DC, 20007, USA

    Christopher E. Attinger

Authors
  1. Victoria K. Shanmugam
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David M. DeMaria
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christopher E. Attinger
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Victoria K. Shanmugam.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Shanmugam, V.K., DeMaria, D.M. & Attinger, C.E. Lower extremity ulcers in rheumatoid arthritis: features and response to immunosuppression. Clin Rheumatol 30, 849–853 (2011). https://doi.org/10.1007/s10067-011-1710-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10067-011-1710-9

Keywords

Search

Navigation