Rheumatoid arthritis (RA) is a chronic autoimmune disease where the immune system mistakenly attacks the body’s own tissues. While RA primarily affects joints, causing inflammation, pain, and swelling, it can also manifest in various other parts of the body, including the face and head.
How Rheumatoid Arthritis Affects the Face and Head
Rheumatoid arthritis can impact the face and head, leading to a range of symptoms. The temporomandibular joint (TMJ), connecting the jawbone to the skull, is a common area affected. Inflammation in the TMJ can cause jaw pain, tenderness, and stiffness, making it difficult to chew or open the mouth fully. People may also experience clicking, popping, or grinding sounds when moving their jaw, and sometimes a change in teeth alignment.
Eye manifestations are also frequent, affecting about 1 in 5 people with RA. Sjögren’s syndrome, characterized by severe dry eyes and dry mouth, is a common associated condition. This dryness can lead to a gritty or burning sensation, irritation, blurred vision, and potentially increase the risk of eye infections or corneal damage.
Beyond dryness, RA can cause inflammation of the eye’s outer layers. Episcleritis, an inflammation of the episclera, results in mild redness and soreness. Scleritis, a more serious condition affecting the sclera (white part of the eye), causes severe pain, intense redness, light sensitivity, and possible vision loss, requiring prompt medical attention. Peripheral ulcerative keratitis, an inflammation of the cornea, can also occur, leading to pain, redness, and vision problems.
Skin changes on the face can also arise from RA. Rheumatoid nodules, firm lumps of tissue, are the most frequent skin manifestation, appearing in about 1 in 4 to 1 in 5 people. While often found around joints, they can appear anywhere, including the face, and typically do not cause pain. Vasculitis, an inflammation of blood vessels, can lead to rashes, red or purplish spots, or painful sores on the skin, including the face, though facial rashes from RA are rare.
Less commonly, nerve involvement can result in facial pain, numbness, or weakness. Peripheral neuropathy, where RA damages nerves, most often affects the hands and feet but can also impact facial nerves. This can manifest as burning, tingling, stabbing pain, or even weakness in the face, such as facial droop.
Inflammation in the cervical spine, or neck, can also contribute to facial and head symptoms. RA can affect the top two neck vertebrae (C1 and C2), leading to neck pain, stiffness, and restricted movement. This inflammation can cause referred pain, manifesting as headaches, particularly at the base of the skull, or pain radiating to the ears or temples if nerves are compressed.
Understanding the Causes of Facial Symptoms
The facial and head symptoms of rheumatoid arthritis stem from the disease’s systemic, autoimmune nature. In RA, the immune system mistakenly targets the body’s own healthy tissues, leading to widespread inflammation. This systemic inflammatory response can affect various tissues and organs.
The immune system’s attack can specifically target the synovial lining of joints, such as the temporomandibular joint. This leads to synovitis, an inflammation causing swelling, pain, and eventual erosion of cartilage and bone. Similarly, in Sjögren’s syndrome, the immune system attacks the lacrimal (tear) and salivary glands, impairing their function and causing dryness.
When blood vessels are affected, vasculitis can develop. This inflammation of small and medium-sized blood vessels can reduce blood flow to the skin and other organs, leading to rashes and ulcers, including on the face. In the eyes, the immune system can attack collagen-containing structures like the sclera and cornea, leading to conditions like scleritis and peripheral ulcerative keratitis.
Chronic inflammation associated with RA can also lead to rheumatoid nodules, which are collections of inflammatory cells forming lumps under the skin. Persistent inflammation in joints like the TMJ or cervical spine can cause bone and cartilage erosion. This structural damage can lead to instability and pressure on nearby nerves, contributing to facial pain, numbness, or weakness.
Diagnosis and Management of Facial Symptoms
Diagnosing RA involvement in the face and head begins with a thorough clinical examination by a rheumatologist. The doctor assesses the temporomandibular joint for tenderness, swelling, and range of motion, and examines the eyes and neck for inflammation or dysfunction. A detailed medical history, including symptom duration and location, also aids diagnosis.
Imaging studies provide further insights into joint damage or inflammation. X-rays, MRI scans of the TMJ or cervical spine, and CT scans can help visualize changes in bone structure, joint alignment, and potential nerve compression. For example, cone-beam CT (CBCT) can reveal early degenerative changes in the TMJ.
Blood tests are also important for confirming RA and monitoring disease activity. Commonly performed tests include erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), and anti-citrullinated protein antibodies (anti-CCP). If specific facial or head symptoms are present, referrals to specialists like dentists, oral surgeons, ophthalmologists, or neurologists are often necessary.
Management of facial and head symptoms primarily focuses on controlling underlying RA with systemic medications. Disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate, sulfasalazine, and hydroxychloroquine, are commonly prescribed to slow disease progression and reduce inflammation. Biologic treatments, a newer class of DMARDs, also interfere with specific immune system pathways to reduce inflammation and are often used for moderate to severe RA.
Symptomatic treatments also address specific facial manifestations. For TMJ pain, nonsteroidal anti-inflammatory drugs (NSAIDs) can reduce swelling and pain. Physical therapy, jaw exercises, and soft diets can improve mobility and lessen discomfort. In some cases, steroid injections into the joint or, rarely, surgical intervention like TMJ reconstruction may be considered for severe damage.
For eye conditions, artificial tears, anti-inflammatory eye drops (including corticosteroids), and punctal plugs can alleviate dryness. More severe conditions like scleritis may require oral steroids or other immunosuppressive medications.
For nerve pain, medications that adjust nerve signals, such as antiseizure drugs or antidepressants, may be used. In some instances, nerve blocks or surgery can provide relief. Cervical spine involvement may be managed with physical therapy, pain medications, and in severe cases, surgical stabilization. A multidisciplinary approach, involving rheumatologists, dentists, oral surgeons, ophthalmologists, and neurologists, offers comprehensive care.