Are leg ulcers in rheumatoid arthritis due to vasculitis?

Five patients with severe rheumatoid arthritis are reported in whom leg ulcers were not apparently associated with vasculitis. The conventional explanation for these ulcers deserves review. Patients with rheumatoid arthritis may develop 'gravitational' leg ulceration and pressure sores on their legs. In addition, they may develop ulcers on the lower aspects of the legs and around the ankles which are well demarcated, punched out, painful and slow to heal. These ulcers usually occur in patients with longstanding, severe, seropositive disease. They are presently considered to be due to a necrotising arteritis causing dermal infarction, since they are frequently associated with other clinical features of rheumatoid vasculitis. Wilkinson has commented that 'biopsies are seldom taken from leg ulcers'. In this paper we report five patients with severe rheumatoid arthritis who developed such leg ulcers in the absence of other clinical evidence of vasculitis and in whom biopsies of the ulcers failed to reveal vasculitis. A case is summarised as illustrative of the five patients, whose relevant histories, clinical findings, and laboratory investigations are summarised in Table 1.