Palisaded neutrophilic and granulomatous dermatitis in rheumatoid arthritis: A case report and a review of literature

Abstract

Palisaded neutrophilic and granulomatous dermatitis (PNGD) is a rare dermatologic condition which shows various clinical and histopathological features. The classic lesions are flesh-colored to erythematous papules, with smooth, crusted or umbilicated surfaces, appearing in a symmetrical distribution on the extensor extremities. However, other locations including trunk, face and scalp have been reported. PNGD can present as pink to violaceus papules, plaques, nodules or urticarial plaques. Some of which show a linear or annular configuration. PNGD usually presents in patients with underlying diseases, such as connective tissue diseases, arthritides, malignancies and patients with administration of some medications. Diagnosis of PNGD depends mainly on histopathology, which is varied depending on the lesion’s age or associated underlying diseases. Because of the recurrence or presence of PNGD usually coincides with the aggravation of underlying diseases. The main principle of PNGD management is to identify the underlying disease and target therapy to control that disorder. We report a case of an 87-year-old woman, with rheumatoid arthritis, who presented with widespread scaly erythematous papules, some coalescing into plaques, on the entire left leg. Histopathology showed perivascular, interstitial and nodular infiltrate of lymphocytes, histiocytes, multinucleated giant cells admixed with nuclear dust and fibrinoid material throughout the dermis. She was diagnosed as having palisaded neutrophilic and granulomatous dermatitis. Initially, she was treated with topical corticosteroid but the lesions progressed to her face. Cyclosporine had been therefore started and given for few weeks; however, she unfortunately developed severe hypertension. Given this, cyclosporine was discontinued and switched to oral cyclophosphamide in combination with prednisolone. Herein, we present the unusual manifestation of PNGD with asymmetrical skin involvement in a patient with rheumatoid arthritis.