August 16, 2021
2 minutes to read
Source / Disclosures
Femia AN. Dermatology for the Rheumatologist, Part I. Presented at: Annual Congress of Clinical Rheumatology-East; August 12-15, 2021 (hybrid meeting).
Disclosures: Femia does not report any relevant financial disclosure.
A thorough physical examination and attention to a patient’s medical history is integral to differentiating between dermatomyositis and dermatomyositis with similar characteristics, according to a presenter here.
“Our two specialties overlap a lot”, Alisa N. Femie, MD, a dermatologist from NYU Langone Health, said in his presentation, particularly between various types of skin dermatomyositis and skin lupus.
As a starting point, Femia encouraged clinicians to “dive” into their patients’ medical histories. She also suggested that patients should be encouraged to document the history of skin changes.
Another tip is to dress the patient in a gown and perform a thorough examination that includes personal or hard-to-reach areas that patients may be reluctant to discuss.
At this point, skin dermatomyositis often occurs on the upper thighs, according to Femia. Additionally, a heliotropic rash on the face is usually skin dermatomyositis and not usually skin lupus.
Gottron papules, commonly found on the hands, are also likely to indicate dermatomyositis rather than lupus. “Lupus really doesn’t like extensor surfaces, whereas dermatomyositis likes extensor surfaces,” Femia said.
Likewise, capillary changes in the nail fold can also cause a rheumatologist to diagnose skin dermatomyositis. In addition, clinically amyopathic dermatomyositis carries the same risk of malignancy and lung damage as its myopathic counterpart, according to Femia.
It is also essential to keep an open mind to correctly diagnose dermatomyositis. Eczema can look like spongiotic dermatitis or even nickel allergy. “If you think you see something on your patient’s skin, follow it up to rule out a diagnosis or lead to a diagnosis, even if there are other factors that are leading you astray,” Femia said.
Protein 5 associated with melanoma differentiation (MDA5– Positive dermatomyositis can present diagnostic challenges, largely because it is typically amyopathic, according to Femia. “It is often associated with interstitial lung disease, which is very often fatal,” she said.
Skin ulcers can be present in MDA5-positive disease, as well as palmar papules, all of which can be “extremely painful,” Femia added. “Treat them with vascular-type therapies,” she said, or drugs that can be used in Raynaud’s phenomenon.
Rheumatologists may be challenged by patients with dysphagia, myositis, periorbital edema, and calcinosis of the skin. “This tends to be one of the most frustrating diagnoses in the world of dermatology,” Femia said.
A combination of medical and surgical interventions may be optimal in these cases. However, because the nodules can be so visually unpleasant, many patients want surgery. “But the nodules only reappear if the underlying disease is not managed,” Femia said. That said, sodium bisphosphonate applied topically or injected intralesionally usually gives the best results in terms of reducing nodules and improving physical appearance.
For patients with immune checkpoint inhibitor-induced myositis, those with typical manifestations tend to have a good prognosis, according to Femia. “More atypical diseases tended to have a worse prognosis,” she said. Immunosuppressive therapy beyond steroids is recommended for this patient population.