RA and Herpes

I don’t believe in coincidence. Karma, yes. Fate, yes. Coincidence, no.

This is especially true in medicine. If you are trapped for hours in an airplane full of hacking, sneezing passengers, it’s really not coincidence that you come down with a cold or the flu within a week. If you step outside in the spring or fall and start sneezing, it’s probably not a coincidence (it’s seasonal allergies). So when, in the midst of a major flare, I had a weird rash show up near my already swollen and tender left elbow, I immediately assumed the outbreak was associated with the flare.

I have sensitive skin, but I’d never had any rashes or other issues around my elbow so this was unusual.

I was already in pain. My RA drug regimen had quit working and most of my joints, particularly from the elbows to the hands in both arms, were painful and swollen. The rash first appeared as an itchy spot right above my left elbow so I immediately applied some cortisone cream. A few hours later I realized that not only was the spot (about the size of a half dollar) not any better, there were a couple of dime-sized spots that had come up close by. And as painful as my joints already were, the rash was a whole dimension of pain beyond that.


I, of course, did an internet search for rashes associated with RA and the most popular response was psoriatic arthritis. But my rash didn’t resemble the scaly red and white patches associated with psoriatic arthritis. On my way over to the dermatologist’s office, I realized that I had seen this outbreak before. It was a fever blister – except that instead of being on my lip, it had broken out on my arm. My dermatologist confirmed the diagnosis and since then I’ve been on an aggressive course of antiviral medication and nerve pain medication. With my compromised immune system, my dermatologist didn’t want the outbreak to spread.

Fever blisters are caused by one of the eight herpes virus strains1 that not only cause fever blisters, but chicken pox, shingles, mononucleosis and certain sarcomas. The relationship of herpes with inflammatory diseases has been known since as early as 1968,2 however it’s not clear whether the viruses play a role in the pathogenesis of these diseases, or if so, how. And while it’s specifically the Epstein-Barr herpes virus strain (EBV) that causes, among other things, mononucleosis, rather than the herpes simplex virus that causes fever blisters that comes into question, the viruses are related. For example, if you’ve had chicken pox as a child, it’s no coincidence that you may have shingles later in life. Several studies have suggested that EBV is associated with autoimmune diseases, such as SLE, RA, MS, autoimmune thyroiditis, inflammatory bowel diseases, insulin-dependent diabetes mellitus, Sjögren’s syndrome, systemic sclerosis, myasthenia gravis, and autoimmune liver diseases. 3 Almost all adult MS patients are positive for EBV.

My dermatologist couldn’t say with any confidence that this outbreak was related to the RA flare I was having on the same arm. He mainly wanted to ensure it was treated properly. I saw my rheumatologist a few days later and she was equally noncommittal. It might be just be an opportunistic virus that was taking advantage of my over-taxed immune system. However as I said earlier, I don’t really believe in coincidence, particularly since the rash and the flare appeared at the same time and seem to be resolving at the same time.

There is a lot that we don’t know about RA, including what causes it and whether the herpes viruses are part of the pathology. Once we do find the cause, we are well on the way to finding cure. But right now, like the old joke, the main difference between true love and herpes (and RA), is that herpes and RA are forever.

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