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Bowel-Associated Dermatosis and Arthritis Syndrome (BADAS) – A Literature Review With Diagnostic and Therapeutic Implications and a Report of Two Cases of BADAS Associated With Inflammatory Bowel Disease Cover

Bowel-Associated Dermatosis and Arthritis Syndrome (BADAS) – A Literature Review With Diagnostic and Therapeutic Implications and a Report of Two Cases of BADAS Associated With Inflammatory Bowel Disease

Open Access
|Feb 2026

Figures & Tables

Fig 1.

(A) Ankle swelling. (A, B) Erythematous macules and papules on the patient’s lower limbs.
(A) Ankle swelling. (A, B) Erythematous macules and papules on the patient’s lower limbs.

Fig 2.

(A, B) Red spots and papules on the patient’s upper limbs. (C) After treatment, on 24-month follow-up.
(A, B) Red spots and papules on the patient’s upper limbs. (C) After treatment, on 24-month follow-up.

Fig 3.

(A, B) Swelling and erythematous spots on the skin and asymmetric swelling of the ankle joints and wrist. (C, D) After treatment, the lesions on the upper and lower limbs healed.
(A, B) Swelling and erythematous spots on the skin and asymmetric swelling of the ankle joints and wrist. (C, D) After treatment, the lesions on the upper and lower limbs healed.

Fig 4.

(A–D) The dermis shows intense perivascular, multicellular inflammatory infiltrates with a dominant neutrophilic component. Damaged blood vessels with fibrinoid necrosis are infiltrated by inflammatory cells. Dermis with elastosis and edema. Image provided by the Dermatology Clinic, PIM MSWIA.
(A–D) The dermis shows intense perivascular, multicellular inflammatory infiltrates with a dominant neutrophilic component. Damaged blood vessels with fibrinoid necrosis are infiltrated by inflammatory cells. Dermis with elastosis and edema. Image provided by the Dermatology Clinic, PIM MSWIA.

Fig 5.

(A, B) Epidermal skin biopsy with focal hyperkeratosis and parakeratosis. Epidermal spinous layer with local acanthosis and flattening of the retinal ridges. Image provided by the Dermatology Clinic, PIM MSWIA.
(A, B) Epidermal skin biopsy with focal hyperkeratosis and parakeratosis. Epidermal spinous layer with local acanthosis and flattening of the retinal ridges. Image provided by the Dermatology Clinic, PIM MSWIA.

Differential diagnosis of BADAS with other neutrophilic dermatoses

DiseaseClinical featuresSkin lesionsDiagnosis
BADAS syndrome
  • -Slow beginning

  • -Recurrent long-term course

  • -History of intestinal diseases

  • -Changes appear with the exacerbation of intestinal symptoms

  • -Accompanied by joint symptoms

  • -Erythematous spots with a diameter of 3–10 mm with blurred borders and a tendency to spread and form nodules (Richar et al. 2021),

  • -Located on the trunk and the proximal parts of upper extremities (Havele et al. 2021; Molinelli et al. 2021),

  • -Moderate pain (Chen et al. 2016; Oldfield et al. 2016; Hassold et al. 2019),

  • -Slow disappearance with no scarring

  • -Clinical picture (coexistence of skin, joint, and intestinal symptoms)

  • (Kurtzman et al. 2016; Ashchyan et al. 2018)

  • -Histopathology

Sweet syndrome
  • -Sudden start

  • -High fever

  • -Sore eyes

  • -Leukocytosis with neutrophilia

  • -Much increased inflammation parameters

  • -Eruptions of painful, soft, purple-violet lumps, nodules, plaques with asymmetrical distribution-Most often located in the area of the upper limbs, head, and neck (Nelson et al. 2018)

  • -Resolution within 72 h after starting systemic therapy

  • -Diagnostic criteria of Su and Liu (1986) with Driesch’s modification

  • -Histopathology (dense neutrophilic infiltrate without signs of vasculitis)

Pyoderma gangrenosum
  • -Usually no accompanying symptoms

  • -Slow progress

  • -Attempted surgical intervention leads to exacerbation

  • -Painful, sparse skin ulcers with irregular, erythematous-purple edges (Maverakis et al. 2018, 2020; Jockenhöfer et al. 2019)

  • -Most often located on the skin of the limbs and appear in places of minor injuries,

  • -Disappears leaving scars (Maverakis et al. 2020)

  • -Clinical picture,

  • -Histopathology (Ahn et al. 2018)

  • -Paracelsus scoring system (Jockenhöfer et al. 2019)

  • -Mayo diagnostic criteria (Su et al. 2004)

  • -Delphi diagnostic criteria

Erythema nodosum-Rarely general symptoms in cases associated with infections or sarcoidosis
  • -Painful erythematous nodules with a diameter of 1–3 cm

  • -Most often located in the lower legs

  • -Usually goes away on its own within 1–6 weeks

  • -Leaving post-inflammatory discolorations

  • -Clinical picture

  • -Histopathology (features of panniculitis) (Förström and Winkelmann 1977)

PPV
  • -Rarely, general symptoms and enlargement of nearby lymph nodes

  • -eosinophilia

  • -Painless or not very painful vesicular and papulopustular lesions

  • -Located mainly on the scalp, face, armpits, and groin lesions have a characteristic appearance of “snail traces” (Antonelli et al. 2021)

  • -Histopathology (Keyal et al. 2018; Tharwat and Eltoraby 2020;)

  • -Eosinophilia

Clinical symptoms of BADAS

Enteric-Associated Dermatosis and Arthritis Syndrome (BADAS)
GI symptoms (%)Skin symptomsRheumatological symptoms
  • Previously diagnosed IBD (65)

  • Abdominal pain (48)

  • Diarrhea (48)

  • Hematochezia (35)

  • Weight loss (26)

  • Erythematous spots, papules, nodules, bullae (100%)

  • Erosions and crusts on the limbs (upper limbs)

  • Fever (82.6%)

  • Arthritis (56.5%)

  • Joint pain (52%)

  • Malaise (30.4%)

  • Achilles tendonitis (1 case)

Treatment algorithm for BADAS with the focus on biologic therapies

4A. Practical treatment algorithm
Disease severityRecommended therapyNotes
Mild–moderateAntibiotics (e.g., metronidazole, ciprofloxacin), Optimize IBD treatment (e.g., 5-ASA, mesalazine)Targeting bacterial overgrowth and intestinal inflammation may be sufficient in early stages and mild flares
Moderate–severe/refractorySystemic GCS – prednisone (0.5–1 mg/kg/day) or MPRemains first-line therapy, choose i.v. MP in severe flares. Can be combined with other immunosuppressants
Steroid-sparing/maintenanceImmunosuppressants (e.g., cyclosporine, azathioprine, MMF), Biologics (anti-TNF, anti-IL-12/23, anti-integrin, anti-IL-1)Choice depends in comorbidities, IBD activity, recurrence rest. Biologics are a key to long-term management
4B. Focus on biologic agents
Agent/classMechanism of actionEvidence in BADAS or other neutrophilic dermatosesPractical notes
Infliximab (anti-TNF-alfa)Monoclonal antibody against TNF-α; suppresses systemic and mucosal inflammationMost frequently reported biologic in BADAS (≥4 cases); strong evidence from IBD and neutrophilic dermatoses literature, including RCTs for pyoderma gangrenosumPreferred option in BADAS with active IBD; rapid onset with great efficacy for the control of bowel, joint, and skin symptoms
Ustekinumab (anti-IL-12/23)Blocks p40 subunit shared by IL-12 and IL-23, reducing Th1/Th17 activityReported in one BADAS case; broader evidence in IBD alone; retrospective, robust case series suggest benefit in neutrophilic dermatosesConsider if anti-TNF is contraindicated or failed; slower onset than infliximab
Vedolizumab (anti-α4β7 integrin)Intestine-selective blockade of lymphocyte traffickingReported in one BADAS case (pediatric); effective in IBD but less reliable for neutrophilic dermatoses (localized mode of action)Best for cases where gut activity drives BADAS – severe IBD flare-up; may be insufficient for systemic/skin inflammation
Canakinumab (anti-IL-1β)Monoclonal antibody against IL-1β; innate immunity inhibitorReported in one BADAS case (pediatric); low level of evidenceReserve for highly refractory BADAS; use only after careful risk–benefit assessment

Information obtained from reviewing published IBD-related BADAS cases

ReferencesSex, age-associated diseasesType of IBD; time from diagnosis of IBD to onset of symptomsSkin lesionsOther symptoms of BADASGI symptomsLaboratory tests findings; endoscopy findingTreatment
Jorizzo et al. (1983)F, 53; disseminated leiomyosarcomaUC diagnosed simultaneously with BADASErythematous papulovesicular, papulopustules with purpuric basesFever, arthralgia, oligoarthritisUnknownLeukocytosis, anemia; pancolitisPRED
Fenske et al. (1983)M, 32; noneUC diagnosed simultaneously with BADASVesicles and pustules with necrosisFeverWeight loss, abdominal cramping, watery diarrheaLeukocytosis; colitisPRED, SSZ
Jorizzo et al. (1984)F, 42; NoneCD unknownErythematous pustulesPolyarthralgiaUnknownUnknownColectomy, no additional therapy
Delaney et al. (1989)M, 46; noneCD diagnosed 1 year before the first symptoms of BADASErythematous macules, vesicopustulesFever, arthritisWeight loss, perianal ulcerationLeukocytosis, accelerated ESR; unknownUnderwent proctocolectomy, PRED, Cloxacillin, AZA
Matheson et al. (1996)F, 16; noneCD diagnosed simultaneously with BADASErythematous, maculopapular, plaques, lesions with pruritisFeverWeight loss, abdominal pain, hematemesis, hematocheziaLeukocytosis, accelerated ESR; deep ulcerations in anus, rectumMP, oral H1 antagonists, topical corticosteroids
Vázquez et al. (2003)M, 34; noneUC was diagnosed 12 years before the first symptoms of BADASErythematous plaques, pustulesFeverSevere diarrhea, abdominal painIn normal ranges; diagnosis of IBDPRED, SSZ
Mendoza et al. (2003)F, 63; episcleritisCD diagnosed simultaneously with BADASErythematous plaques, nodules, vesicopustulesFever, asymmetrical polyarthralgiaWeight loss, abdominal pain, mucosal stool movementAnemia; multiple deep, wide ulcers alternating with normal mucosal from the sigmoid colon and ascending 70 cmMP
Guerre-Schmidt et al. (2006)F, 13, noneCD diagnosed simultaneously with BADASErythematous pustulesFever, oligoarthritisWeight loss, rectal bleedingAnemia, elevated CRP; ulcerated appearance of area of appendixPRED
Ashok and Kiely (2007)M, 23, noneCD was diagnosed 4 years before the first BADAS symptomsErythematous macules, papules, vesicopustularFever, arthritis, arthralgia, malaiseStomal diarrhea, abdominal pain, vomitingLeucocytosis, accelerated ESR, elevated CRP; unknownPRED
Kinyó et al. (2011)M, 32, noneCD diagnosed simultaneously with BADASVesiculopustu les on erythematous baseFever, arthritisBloody diarrheaLeucocytosis, accelerated ESR, elevated CRP; Pancolitis. An ulcerated, granulomatous with abscess formationMP, Metronidaz ole, cefuroxime, CsA, AZA
Lacey et al. (2011)F, 24, noneUC diagnosed simultane ously with BADASPustular lesions, non-tenderFever, malaiseAbdominal pain, diarrhea, hematocheziaLeucocytosis; Severe UCMP pulses, Metronidazole, Ciprofl oxacin, PRED, AZA
Truchuelo et al. (2013)F, 35, noneUC diagnosed previous than BADASErythematous plaques, nodules, vesicopustules with erythematous halo, painfulFever, polyarthritis, malaiseAstheniaAccelerated ESR; unknownPRED, metronidazole
DeFilippis et al. (2014)F, 64; depression, osteoporosis, spinal stenosisUC was diagnosed 20 years before the firstErythematous-violaceous maculesArthralgia, arthritisAbdominal pain, diarrheaAccelerated ESR, elevated CRP; active microscopic inflammation on a right colonPRED, MMF, SSZ
DeFilippis et al. (2014)F, 64; depression, osteoporosis, spinal stenosis, gastroesophageal refluxUC was diagnosed 20 years before the first symptoms of BADASErythematous-violaceous maculesArthralgia, arthritisAbdominal pain, diarrheaAccelerated ESR, elevated CRP; active microscopic inflammation on a right colonInfliximab, MMF, SSZ
Aounallah et al. (2016)F, 39, unknownUC diagnosed previous than BADASVesicles and pustulesFever, arthralgiaUnknownUnknownPRED, AZA, CsA
Oldfield et al. (2016)F, 4, sickle cell disease, autoimmune hepatitisUC diagnosed previous than BADASHemorrhagic vesiclesFever, arthritis, malaiseAbdominal pain, congestion, hematocheziaLeucocytosis, anemia, elevated CRP; unknownPRED, Metronidazole, Mesalazine, AZA, infliximab
Barland et al. (2016)F, 42, unknownCD was diagnosed 10 years before the first symptoms of BADASErythematous nodules, vesiculopustulesArthalgiaUnknownAnemia, elevated CRP; unknownMesalazine, doxycycline
Heard et al. (2020)F, 49, depression, anxiety, mitral valve prolapse, strokeCD was diagnosed earlier than the onset of BADAS, but the date is unknownErythematous vesiculopustule, erosionsFever, arthralgiaDiarrhea, rectal bleeding, dehydrationAnemia; severe ulceration in rectum and sigmoidPiperacillin + tazobactam, ustekinumab
Havele et al. (2021)M, 6, immune dysfunction, recurrent fever, uveitisVEO-IBD diagnosed simultaneously with BADASErythematous papules, vesiculopustules tenderFever, arthralgiaIncrease rectal output, vomiting, oral ulcersUnknownInfliximab, cedolizuma b, canakinum ab, mesalazine, ileostomy
Havele et al. (2021)M, 6, Immune dysfunction, recurrent fever, uveitisVEO-IBD diagnosed simultaneously with BADASErythematous papules, vesiculopustules tenderFever, arthralgiaIncrease rectal output, vomiting, oral ulcersUnknownTriamcinol one topical
Havele et al. (2021)M, 6, immune dysfunction, recurrent fever, uveitisVEO-IBD diagnosed simultaneously with BADASErythematous papules, vesiculopustules tenderFever, arthalgiaIncrease rectal output, vomiting, oral ulcersUnknownSubtotal colectomy, triamcinol one topical, ruxolitinib
Caro et al. (2021)F, 78, erythema nodosumUC diagnosed simultaneously with BADASErythematous and purple plaques, nodules,Arthralgia, arthritisAbdominal pain, diarrhea, tenesmus, mucus in stoolaccelerated ESR, elevated CRP; a recto sigmoid UCMesalazine, rifaximin
Russell Johns et al. (2022)F, 14; noneUC diagnosed simultaneously with BADASViolaceous nodules, indurated plaques, painful,Fever, migratory arthritis, malaiseAbdominal cramping, bloody diarrheaLeucocytosis, anemia, accelerated ESR, elevated CRP; eosinophilic colitis from the rectum to the sigmoid colonMP pulses, followed by PRED + SS Z followed by infliximab + SSZ
Alshahrani et al. (2022)M, 39; noneUC was diagnosed 3 years before the symptoms of BADASErythematous papular, maculopapular, urticaria-like, vesiculopustular lesionsFever, Polyarteritis, Achilles tendinitis, malaiseWeight loss, bloody diarrhea,Anemia, accelerated ESR, elevated CRP; hyperemia with mild edematous mucosal changes in the sigmoid colonPRED, Mesalazine, Metronidaz ole, Fluoroquinolone, AZA
Case 1 (in our present publication)F, 30; beta thalassemiaUC diagnosis in 2012, first symptoms of BADAS in 2017, BADAS diagnosis in 2021Edematous erythematous macules, maculopapular lesionsFever, arthritis, arthralgia malaiseBloody diarrheaAnemia, elevated CRP, high D-dimer – 6478 ng/mL; unknownPRED, Mesalazine, Cefuroxime, Fluoroquinolone, CsA, AZA
Case 2 (in our present publication)M, 67; benign prostatic hyperplasia, osteoarthritisCD diagnosed in 2020, BADAS diagnosed in 2023Edematous erythematous macules, maculopapular, vesicopustular lesionsFever, arthritis, arthralgiaAbdominal pain, diarrhea, mucus in stoolLeucocytosis, anemia, elevated CRP, high D-dimer – 7200 ng/mL; the entire length of the sigmoid colon and the final section of the descending colon with a thickened, swollen wallMetronidazole, PRED, ciprofloxacin, topical clobetasol propionate, infliximab
Language: English
Submitted on: Sep 10, 2025
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Accepted on: Nov 21, 2025
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Published on: Feb 21, 2026
In partnership with: Paradigm Publishing Services
Publication frequency: 1 issue per year

© 2026 Raman Nitskovich, Aleksandra Jóźwik, Piotr Sobolewski, Paweł Głuszak, Dagmara S. Mahadea, Irena Walecka, published by Hirszfeld Institute of Immunology and Experimental Therapy
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.