Dermatomyositis

Lichenoid and interface dermatoses

The terms 'lichenoid' and 'interface' dermatitis are often used interchangeably to describe an inflammatory pattern characterized histologically by damage to the basal keratinocytes in the epidermis. The mechanism of cell damage of such cells is now best understood as apoptosis, or programmed cell death. This inflammatory pattern of dermatoses, is also accompanied frequently by a band of lymphocytes and histiocytes in the superficial dermis, that often obscures the dermal-epidermal junction, hence the term 'lichenoid'. A discussion of the more common lichenoid/interface dermatitides encountered in the routine clinical practice encompasses the following entities: lichen planus, lupus erythematosus, dermatomyositis, erythema multiforme, graft versus host disease, fixed drug reactions, and multiple others.

Topical tacrolimus 0.1% ointment for refractory skin disease in dermatomyositis: a pilot study

BACKGROUND

Dermatomyositis is an inflammatory disease primarily involving the striated muscles and skin. Muscle disease usually responds to aggressive therapy with systemic corticosteroids. However, cutaneous lesions can be very resistant to systemic and topical therapies, even in combination. More treatment options are needed. Tacrolimus is an immunomodulator now available in a topical ointment.

OBJECTIVE

To study the treatment of patients with refractory cutaneous lesions of dermatomyositis using topical tacrolimus 0.1% ointment.

METHODS

Six patients with recalcitrant cutaneous lesions of dermatomyositis were included in this brief observational study: five adults and one pediatric patient. Five patients had classic dermatomyositis and one had dermatomyositis sine myositis.

RESULTS

All had some degree of improvement of their dermatologic disease following 6-8 weeks of treatment with topical tacrolimus 0.1% ointment. Two had dramatic responses (>90% improvement), one had moderate (40-90%) improvement and three had minimal (20-40%) improvement.

CONCLUSIONS

The dermatologic manifestations of dermatomyositis can be very difficult to treat. Multiple systemic and topical therapies have been studied. Combinations of treatments are often used, sometimes still not successfully. The results of this brief observational study using topical tacrolimus ointment for the treatment of refractory cutaneous lesions of dermatomyositis are encouraging. Topical tacrolimus was a useful adjunct in the treatment of the dermatologic component of dermatomyositis in adults and children in this pilot study.

Dermatomyositis: a dermatology-based case series

BACKGROUND

Dermatomyositis is associated with significant morbidity and occasional mortality. Currently there is no consensus on treatment for patients with dermatomyositis.

OBJECTIVE

Our purpose was to review the clinical features and response to therapy of patients with dermatomyositis and compare these data with previous series of patients with dermatomyositis/polymyositis.

METHODS

Clinical characteristics of 65 patients seen during a 10-year period were reviewed retrospectively. Twenty-one of these patients were enrolled in a prospective, uncontrolled study of treatment with high-dose prednisone followed by slow tapering.

RESULTS

Clinical features were similar to those previously described; however, muscle strength at diagnosis was on average greater in patients in this series than in patients previously reported. Malignancy was present in 5 of 43 adult patients (12%), but was not found in patients with juvenile dermatomyositis. Another connective tissue disease was present in 19% of patients. Twelve patients had dermatomyositis sine myositis. Eighteen of 21 patients (85%) in the prednisone study group had resolution of myositis.

CONCLUSION

Patients with dermatomyositis in this series had less active myositis at presentation, but were otherwise similar to patients with dermatomyositis/polymyositis previously reported. Treatment with high-dose daily prednisone followed by slow tapering was effective.

Low-dose methotrexate administered weekly is an effective corticosteroid-sparing agent for the treatment of the cutaneous manifestations of dermatomyositis

BACKGROUND

The cutaneous manifestations of dermatomyositis can be the most prominent finding and are often difficult to treat.

OBJECTIVE

Our purpose was to determine whether low-dose methotrexate administered weekly in combination with other systemic therapies or as a sole systemic agent is effective in the treatment of the cutaneous disease in patients with dermatomyositis.

METHODS

We reviewed the records of 13 patients who received oral methotrexate in doses ranging from 2.5 to 30 mg weekly. Their skin lesions had not been completely responsive to sunscreens, topical corticosteroids, oral prednisone, oral antimalarial therapy, and, in one patient each, chlorambucil and azathioprine.

RESULTS

At the end of the study period, 4 of these 13 patients were free of all cutaneous manifestations of dermatomyositis, and another four had almost complete clearing. In the remaining five patients, methotrexate induced moderate clearing of their cutaneous lesions. In all patients, the addition of methotrexate allowed reduction or discontinuation of other therapies such as prednisone. All patients tolerated the methotrexate with minimal toxicity.

CONCLUSIONS

Low-dose oral methotrexate administered weekly is effective in treatment of the cutaneous manifestations of dermatomyositis and frequently enables a reduction or discontinuation of corticosteroid therapy.

Connection of atopic disease in Japanese patients with juvenile dermatomyositis based on serum IgE levels

Serum IgE levels of 22 patients with juvenile dermatomyositis (JDMS), 44 normal children, and 43 patients with adult dermatomyositis were compared. The geometric mean of serum IgE levels was significantly higher in the juvenile patients when compared with normal children (p < 0.01) and adult patients (p < 0.01). Of the 22 patients with JDMS, 11 (50%) had elevated serum IgE levels accompanied by atopic disease. Dermatomyositis was accompanied by atopic dermatitis (AD) in 9 (41%) of these 22 patients, a high prevalence when compared with reports among the general population. Following the appearance of muscular symptoms in JDMS patients with AD, the ratio of OKT4 to OKT8 cells rose due to a reduction in the percentage of OKT8-positive cells, along with further elevations in serum IgE levels and intractable cutaneous manifestations of dermatomyositis. All this may be a result of an interaction between the immuno-mechanism of this disease and that of AD. We suspect that, in general, children with impaired cell-mediated immunity, presenting with such symptoms as AD, may have a higher tendency for developing JDMS.

Juvenile dermatomyositis: a statistical study of 114 patients with dermatomyositis

We conducted a statistical review of 114 cases of dermatomyositis (DMS) treated primarily at the Department of Dermatology at Nagoya University Hospital over 27 years from 1965 to 1991 in order to determine the primary characteristics of juvenile DMS with the following results. 1) Juvenile DMS was found slightly more often in males than females; the male-to-female ratio was 1.4:1. Therefore, unlike adult DMS with its preponderance of females, there was no clear gender predominance. 2) Muscular manifestations tended to follow the appearance of cutaneous manifestations, but the frequency of minor muscular manifestations was high over the entire course of the disease. 3) Laboratory findings showed increases in serum aldolase and serum creatinine kinase with significant frequency when compared with adult patients (p < 0.01 and p < 0.05, respectively). Elevated serum aldolase most often occurred prior to or at the time of the appearance of muscular manifestations, suggesting its usefulness in early diagnosis. The positive rates for the antinuclear antibody on HEp-2 cells and anti-DNA antibody were significantly lower in children than in adults (p < 0.001 and p < 0.05, respectively). 4) There were no cases of juvenile DMS complicated by malignant tumors, interstitial pneumonia, or pulmonary fibrosis. There were also no deaths, and the rate of "remission or improvement" was significantly higher than in adult DMS cases (p < 0.05). Adult cases which remained the same or worsened usually presented with intractable muscular manifestations. In children, however, the cutaneous manifestations were more difficult to treat.(ABSTRACT TRUNCATED AT 250 WORDS)

Microvascular changes in skeletal muscle in idiopathic inflammatory myopathy

Open deltoid muscle biopsy specimens from patients with idiopathic adult dermatomyositis, paraneoplastic dermatomyositis, childhood dermatomyositis, and idiopathic polymyositis, and from control patients were studied. Qualitative and morphometric capillary analysis by phase and electron microscopy was carried out. In the morphologic analysis the most striking difference was the presence of capillary damage and a higher capillary depletion in dermatomyositis as well as a higher capillary density in polymyositis. By electron microscopy, capillaries from patients with dermatomyositis showed mainly microtubuloreticular structures, loss of endothelial plasma membranes, and the appearance of abnormal cytoplasmic organelles. In contrast, capillaries from patients with polymyositis exhibited only minimal changes. By morphometric analysis, muscle capillaries in dermatomyositis had a significantly higher mean endothelial thickness than those in polymyositis. Finally, a significant topographic association between capillary damage and muscle fiber changes was observed only in patients with dermatomyositis. On the other hand, paraneoplastic dermatomyositis showed fewer structural and morphometric capillary changes than the other forms of dermatomyositis. We conclude that dermatomyositis is characterized by microvascular alterations that are absent in polymyositis. The topographic proximity of capillary changes to muscle fiber injury suggests that capillary damage may play a role in the pathogenesis of the muscle lesions observed in patients with dermatomyositis.

Current management of polymyositis and dermatomyositis

This article reviews the clinical features and emphasises the treatment of polymyositis and dermatomyositis. Pharmacological intervention with corticosteroids and immunosuppressive agents is discussed. In addition, strategies regarding the initiation and subsequent tapering of these drugs are provided, and an algorithmic approach to the management of myositis is provided. Therapeutic modalities for patients with refractory disease are considered, and the potential adverse effects of such treatment are discussed. Since patients with myositis often have disease-related complaints other than muscle weakness, a practical treatment approach for these problems is also outlined.