Can you get this one?

Satyam Bhatt MD Medicine, DrNB Clinical Immunology and Rheumatology
Assistant Professor, Department of Clinical Immunology & Rheumatology, Geetanjali Medical College & Hospital, Udaipur, Rajasthan

This 50-year-old lady, a known case of Rheumatoid Arthritis with hand deformities, presented with painless cutaneous lesions as shown in the image. She was in clinical remission on conventional DMARD therapy. Identify these lesions and tell the further course of management.

Answer: Bywaters' lesions are characteristic but uncommon cutaneous manifestations seen in rheumatoid arthritis (RA) patients, first described in 1949 by Eric George Lapthorne Bywaters, an English professor of Rheumatology. They compriseof nail-fold thrombosis and reddish-brown-purpuric papules on distal phalanges. Histology shows presence of small vessel leukocytoclastic vasculitis. Typically, these lesions are not associated with systemic signs or symptoms of vasculitis. They do not correlate with RA disease activity and require no additional treatment.
This patient was assured clinically and no additional drugs were prescribed.