- Author: Alisa N Femia, MD; Chief Editor: Herbert S Diamond, MD more...
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. In addition to the agents listed below, colchicine, alendronate, and warfarin, amongst other therapies, have been shown to be potentially beneficial for the treatment of calcinosis.
Prednisone is the first-line therapy for muscle involvement in dermatomyositis. The dose is altered according to the response of the patient’s condition.
Antimalarials, particularly hydroxychloroquine, may be useful for cutaneous disease; however, the majority of patients with cutaneous involvement require additional immunomodulatory medications for adequate control. Patients with dermatomyositis are at increased risk for drug eruptions with hydroxychloroquine.
Immunosuppressive/cytotoxic drugs are used as steroid-sparing agents for the muscle disease of dermatomyositis. Methotrexate has been demonstrated to be useful for skin disease, even in the absence of significant muscle disease, and is considered by many experts in the field to be first-line therapy for patients in whom antimalarials fail.[96, 97, 64, 35] Mycophenolate mofetil may also be useful for cutaneous disease. Intravenous immunoglobulin (IVIG) is also beneficial for both cutaneous and muscular involvement.
Biologic therapies have been investigated as potential therapeutic options for dermatomyositis. Existing data regarding anti–tumor necrosis factor alpha therapies have been mixed, and raise potential concerns for use in the dermatomyositis population. Therefore, their widespread use is discouraged until adequate, preferably controlled, studies demonstrate their efficacy and safety.
A small, double-blind, placebo-controlled study of etanercept demonstrated a steroid-sparing effect in five of 11 etanercept-treated patients versus treatment failure in all five placebo-treated patients. The effects were mostly on muscle disease, but some positive effects on skin disease were noted, utilizing the Cutaneous Dermatomyositis Area and Severity Index (CDASI) as a measure. However, two patients in the treated group developed rash, and two developed antinuclear antibodies. One patient in the placebo group developed ovarian cancer, but none in the etanercept group developed cancer during the year-long treatment period.
In addition, one retrospective review of eight patients with dermatomyositis or polymyositis treated with etanercept reported improvement in muscle disease in six patients. However, a case series of five patients with dermatomyositis treated with etancercept found exacerbation of myositis and no improvement in skin disease in any patient.
Infliximab has also been investigated in patients with dermatomyositis; however, results have not been promising. In an open study of 13 patients with refractory myositis, no improvement with infliximab was noted. In addition, one study of infliximab combined with methotrexate for patients with myositis was terminated early due to a high drop-out rate and low inclusion rate.
For these reasons, and because there are several reports of dermatomyositis induced by anti-tumor necrosis factor, anti–tumor necrosis factor therapies should be used only rarely and with caution in patients with severe refractory dermatomyositis.
Disease-Modifying Antirheumatic Drugs
Disease-modifying antirheumatic drugs (DMARDs) can retard or prevent disease progression and, thus, joint destruction and subsequent loss of function.
Immunomodulatory agent; inhibits pyrimidine synthesis, which in turn results in antiproliferative and aniti-inflammatory effects.
The mainstay of therapy for patients with dermatomyositis and muscle involvement is systemic corticosteroids. Cutaneous disease has a variable response to systemic corticosteroids. Disease with pulmonary or cardiac involvement may respond, whereas disease involving esophageal dysfunction usually does not respond. Glucocorticoids may be used topically for cutaneous disease.
Prednisone is first-line therapy for dermatomyositis. It may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) leukocyte activity. It may be beneficial to use intravenous (IV) pulses; this may be associated with a lower frequency of calcinosis.
Corticosteroids may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) leukocyte activity. Shown to improve patients with inflammatory myositis.
Immunosuppressive agents are used early in the treatment course as steroid-sparing agents. They decrease the risk of steroid-related complications.
Methotrexate is used for managing constitutional symptoms. It blocks purine synthesis and 5-aminoimidazole-4-carboxamide ribonucleotide (AICAR), thus increasing anti-inflammatory adenosine concentration at sites of inflammation. Methotrexate ameliorates symptoms of inflammation.
Azathioprine is a purine analogue that inhibits purine synthesis, resulting in inhibition of DNA, RNA, and protein synthesis. It may decrease proliferation of immune cells, thereby leading to lower autoimmune activity. It has few, if any, effects on the skin.
Mycophenolate is useful for both skin and muscle disease. It inhibits purine synthesis and proliferation of human lymphocytes.
Sirolimus inhibits lymphocyte proliferation by interfering with signal transduction pathways. It binds to immunophilin FK506 binding protein (FKBP) to block the action of mammalian target of rapamycin (mTOR). It is approved by the US Food and Drug Administration (FDA) for prophylaxis against organ rejection in patients receiving allogeneic renal allografts.
A cyclosporine-sparing regimen has recently been FDA-approved for patients with low-to-moderate rejection risk at 2-4 months after transplantation. This regimen allows cyclosporine to be withdrawn, thus significantly decreasing renal toxicity while maintaining a similar antirejection effect.
Rituximab is a third-line choice for the treatment of dermatomyositis. It is a genetically engineered chimeric murine/human monoclonal antibody directed against the CD20 antigen found on the surface of normal and malignant B lymphocytes. It is an IgG1-kappa immunoglobulin that contains murine light- and heavy-chain variable region sequences and human constant region sequences.
Cyclophosphamide is used for immunosuppression in cases of autoimmune disorders. This agent is chemically related to nitrogen mustards. As an alkylating agent, the mechanism of action of the active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells.
Cyclosporine (Gengraf, Neoral, Sandimmune)
Cyclosporine is a cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions.
Chlorambucil alkylates and cross-links strands of DNA, inhibiting DNA replication and RNA transcription.
High-dose IVIG has been reported to be useful in patients with recalcitrant dermatomyositis.
IVIG is useful for patients in whom corticosteroids and immunosuppressants have failed.
Calcium Channel Blockers
Calcium channel blockers may be useful for treating calcinosis.
During depolarization, diltiazem inhibits calcium ions from entering the slow channels and voltage-sensitive areas of vascular smooth muscle and myocardium. Treatment of calcinosis is an off-label use (the mechanism of action is unknown). It appears that other calcium channel blockers are not effective in this setting.
Calcium Metabolism Modifiers
Bisphosphonates are used to treat hypercalcemia and to decrease calcium loss from bone.
Pamidronate inhibits bone resorption via actions on osteoclasts or on osteoclast precursors, without significant effects on renal tubular calcium handling. It is indicated for treatment of hypercalcemia. Intravenous (IV) pamidronate has been demonstrated in several cases to result in resolution of the calcinosis.
Alendronate has been successful in treating the pain of PFD; it may have some benefit in increasing bone mineral density as well. It offers the additional benefit of oral administration. Inhibits bone resorption via actions on osteoclasts or on osteoclast precursors. Has been shown to be potentially beneficial for the treatment of calcinosis
Antimalarial agents may be used as steroid-sparing agents to treat skin disease. Hydroxychloroquine is preferred; chloroquine and quinacrine (100 mg/day) are second-line agents. Quinacrine may suppress bone marrow and is distributed by the Centers for Disease Control and Prevention (CDC); blood cell counts should be obtained regularly.
Hydroxychloroquine may allow partial or complete control of the disease. Anecdotal evidence has suggested that morbilliform drug reactions are more common in patients with dermatomyositis than in those with other collagen vascular diseases. Hydroxychloroquine inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions.
Chloroquine phosphate inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions.
Callen JP. Dermatomyositis. Lancet. 2000 Jan 1. 355(9197):53-7. [Medline].
Callen JP, Wortmann RL. Dermatomyositis. Clin Dermatol. 2006 Sep-Oct. 24(5):363-73. [Medline].
Kasteler JS, Callen JP. Scalp involvement in dermatomyositis. Often overlooked or misdiagnosed. JAMA. 1994 Dec 28. 272(24):1939-41. [Medline].
Airio A, Pukkala E, Isomäki H. Elevated cancer incidence in patients with dermatomyositis: a population based study. J Rheumatol. 1995 Jul. 22(7):1300-3. [Medline].
Chow WH, Gridley G, Mellemkjaer L, McLaughlin JK, Olsen JH, Fraumeni JF Jr. Cancer risk following polymyositis and dermatomyositis: a nationwide cohort study in Denmark. Cancer Causes Control. 1995 Jan. 6(1):9-13. [Medline].
Hill CL, Zhang Y, Sigurgeirsson B, et al. Frequency of specific cancer types in dermatomyositis and polymyositis: a population-based study. Lancet. 2001 Jan 13. 357(9250):96-100. [Medline].
Sigurgeirsson B, Lindelöf B, Edhag O, Allander E. Risk of cancer in patients with dermatomyositis or polymyositis. A population-based study. N Engl J Med. 1992 Feb 6. 326(6):363-7. [Medline].
Antiochos BB, Brown LA, Li Z, Tosteson TD, Wortmann RL, Rigby WF. Malignancy is associated with dermatomyositis but not polymyositis in Northern New England, USA. J Rheumatol. 2009 Dec. 36(12):2704-10. [Medline].
Fardet L, Dupuy A, Gain M, et al. Factors associated with underlying malignancy in a retrospective cohort of 121 patients with dermatomyositis. Medicine (Baltimore). 2009 Mar. 88(2):91-7. [Medline].
Bohan A, Peter JB. Polymyositis and dermatomyositis (second of two parts). N Engl J Med. 1975 Feb 20. 292(8):403-7. [Medline].
Bohan A, Peter JB. Polymyositis and dermatomyositis (first of two parts). N Engl J Med. 1975 Feb 13. 292(7):344-7. [Medline].
Sontheimer RD. Would a new name hasten the acceptance of amyopathic dermatomyositis (dermatomyositis siné myositis) as a distinctive subset within the idiopathic inflammatory dermatomyopathies spectrum of clinical illness?. J Am Acad Dermatol. 2002 Apr. 46(4):626-36. [Medline].
Bendewald MJ, Wetter DA, Li X, Davis MD. Incidence of dermatomyositis and clinically amyopathic dermatomyositis: a population-based study in Olmsted County, Minnesota. Arch Dermatol. 2010 Jan. 146(1):26-30. [Medline]. [Full Text].
Klein RQ, Teal V, Taylor L, Troxel AB, Werth VP. Number, characteristics, and classification of patients with dermatomyositis seen by dermatology and rheumatology departments at a large tertiary medical center. J Am Acad Dermatol. 2007 Dec. 57(6):937-43. [Medline].
Sun Y, Liu Y, Yan B, Shi G. Interstitial lung disease in clinically amyopathic dermatomyositis (CADM) patients: a retrospective study of 41 Chinese Han patients. Rheumatol Int. 2013 May. 33(5):1295-302. [Medline].
Gerami P, Schope JM, McDonald L, Walling HW, Sontheimer RD. A systematic review of adult-onset clinically amyopathic dermatomyositis (dermatomyositis siné myositis): a missing link within the spectrum of the idiopathic inflammatory myopathies. J Am Acad Dermatol. 2006 Apr. 54(4):597-613. [Medline].
Levine TD. Rituximab in the treatment of dermatomyositis: an open-label pilot study. Arthritis Rheum. 2005 Feb. 52(2):601-7. [Medline].
Chung L, Genovese MC, Fiorentino DF. A pilot trial of rituximab in the treatment of patients with dermatomyositis. Arch Dermatol. 2007 Jun. 143(6):763-7. [Medline].
Banker BQ, Victor M. Dermatomyositis (systemic angiopathy) of childhood. Medicine (Baltimore). 1966 Jul. 45(4):261-89. [Medline].
Werth VP, Callen JP, Ang G, Sullivan KE. Associations of tumor necrosis factor alpha and HLA polymorphisms with adult dermatomyositis: implications for a unique pathogenesis. J Invest Dermatol. 2002 Sep. 119(3):617-20. [Medline].
Pachman LM, Veis A, Stock S, et al. Composition of calcifications in children with juvenile dermatomyositis: association with chronic cutaneous inflammation. Arthritis Rheum. 2006 Oct. 54(10):3345-50. [Medline]. [Full Text].
Lutz J, Huwiler KG, Fedczyna T, et al. Increased plasma thrombospondin-1 (TSP-1) levels are associated with the TNF alpha-308A allele in children with juvenile dermatomyositis. Clin Immunol. 2002 Jun. 103(3 Pt 1):260-3. [Medline].
Chen S, Wang Q, Wu Z, Wu Q, Li P, Li Y, et al. Associations between TNF-a-308A/G Polymorphism and Susceptibility with Dermatomyositis: A Meta-Analysis. PLoS One. 2014. 9(8):e102841. [Medline]. [Full Text].
Daoud MS, Gibson LE, Pittelkow MR. Hydroxyurea dermopathy: a unique lichenoid eruption complicating long-term therapy with hydroxyurea. J Am Acad Dermatol. 1997 Feb. 36(2 Pt 1):178-82. [Medline].
Noël B. Lupus erythematosus and other autoimmune diseases related to statin therapy: a systematic review. J Eur Acad Dermatol Venereol. 2007 Jan. 21(1):17-24. [Medline].
O'Hanlon T, Koneru B, Bayat E, Love L, Targoff I, Malley J, et al. Immunogenetic differences between Caucasian women with and those without silicone implants in whom myositis develops. Arthritis Rheum. 2004 Nov. 50(11):3646-50. [Medline].
Callen JP, Hyla JF, Bole GG Jr, Kay DR. The relationship of dermatomyositis and polymyositis to internal malignancy. Arch Dermatol. 1980 Mar. 116(3):295-8. [Medline].
Buchbinder R, Forbes A, Hall S, Dennett X, Giles G. Incidence of malignant disease in biopsy-proven inflammatory myopathy. A population-based cohort study. Ann Intern Med. 2001 Jun 19. 134(12):1087-95. [Medline].
Chow WH, Gridley G, Mellemkjaer L, McLaughlin JK, Olsen JH, Fraumeni JF Jr. Cancer risk following polymyositis and dermatomyositis: a nationwide cohort study in Denmark. Cancer Causes Control. 1995 Jan. 6(1):9-13. [Medline].
Limaye V, Luke C, Tucker G, Hill C, Lester S, Blumbergs P, et al. The incidence and associations of malignancy in a large cohort of patients with biopsy-determined idiopathic inflammatory myositis. Rheumatol Int. 2013 Apr. 33(4):965-71. [Medline].
So MW, Koo BS, Kim YG, Lee CK, Yoo B. Idiopathic inflammatory myopathy associated with malignancy: a retrospective cohort of 151 Korean patients with dermatomyositis and polymyositis. J Rheumatol. 2011 Nov. 38(11):2432-5. [Medline].
Zantos D, Zhang Y, Felson D. The overall and temporal association of cancer with polymyositis and dermatomyositis. J Rheumatol. 1994 Oct. 21(10):1855-9. [Medline].
Stockton D, Doherty VR, Brewster DH. Risk of cancer in patients with dermatomyositis or polymyositis, and follow-up implications: a Scottish population-based cohort study. Br J Cancer. 2001 Jul 6. 85(1):41-5. [Medline]. [Full Text].
Femia AN, Vleugels RA, Callen JP. Cutaneous dermatomyositis: an updated review of treatment options and internal associations. Am J Clin Dermatol. 2013 Aug. 14(4):291-313. [Medline].
Huang YL, Chen YJ, Lin MW, Wu CY, Liu PC, Chen TJ, et al. Malignancies associated with dermatomyositis and polymyositis in Taiwan: a nationwide population-based study. Br J Dermatol. 2009 Oct. 161(4):854-60. [Medline].
Kuo CF, See LC, Yu KH, Chou IJ, Chang HC, Chiou MJ, et al. Incidence, cancer risk and mortality of dermatomyositis and polymyositis in Taiwan: a nationwide population study. Br J Dermatol. 2011 Dec. 165(6):1273-9. [Medline].
Liu WC, Ho M, Koh WP, Tan AW, Ng PP, Chua SH, et al. An 11-year review of dermatomyositis in Asian patients. Ann Acad Med Singapore. 2010 Nov. 39(11):843-7. [Medline].
Chen D, Yuan S, Wu X, Li H, Qiu Q, Zhan Z, et al. Incidence and predictive factors for malignancies with dermatomyositis: a cohort from southern China. Clin Exp Rheumatol. 2014 Jul 28. [Medline].
Valenzuela A, Chung L, Casciola-Rosen L, Fiorentino D. Identification of clinical features and autoantibodies associated with calcinosis in dermatomyositis. JAMA Dermatol. 2014 Jul. 150(7):724-9. [Medline].
Rai SK, Choi HK, Sayre EC, Aviña-Zubieta JA. Risk of myocardial infarction and ischaemic stroke in adults with polymyositis and dermatomyositis: a general population-based study. Rheumatology (Oxford). 2015 Sep 30. [Medline].
Lee CW, Muo CH, Liang JA, Sung FC, Hsu CY, Kao CH. Increased osteoporosis risk in dermatomyositis or polymyositis independent of the treatments: a population-based cohort study with propensity score. Endocrine. 2015 Oct 1. [Medline].
Seidler AM, Gottlieb AB. Dermatomyositis induced by drug therapy: a review of case reports. J Am Acad Dermatol. 2008 Nov. 59(5):872-80. [Medline].
Labirua-Iturburu A, Selva-O'Callaghan A, Vincze M, Dankó K, Vencovsky J, Fisher B, et al. Anti-PL-7 (anti-threonyl-tRNA synthetase) antisynthetase syndrome: clinical manifestations in a series of patients from a European multicenter study (EUMYONET) and review of the literature. Medicine (Baltimore). 2012 Jul. 91(4):206-11. [Medline].
Trallero-Araguás E, Labrador-Horrillo M, Selva-O'Callaghan A, et al. Cancer-associated myositis and anti-p155 autoantibody in a series of 85 patients with idiopathic inflammatory myopathy. Medicine (Baltimore). 2010 Jan. 89(1):47-52. [Medline].
Trallero-Araguás E, Rodrigo-Pendás JÁ, Selva-O'Callaghan A, Martínez-Gómez X, Bosch X, Labrador-Horrillo M, et al. Usefulness of anti-p155 autoantibody for diagnosing cancer-associated dermatomyositis: a systematic review and meta-analysis. Arthritis Rheum. 2012 Feb. 64(2):523-32. [Medline].
Hamaguchi Y, Kuwana M, Hoshino K, Hasegawa M, Kaji K, Matsushita T, et al. Clinical correlations with dermatomyositis-specific autoantibodies in adult Japanese patients with dermatomyositis: a multicenter cross-sectional study. Arch Dermatol. 2011 Apr. 147(4):391-8. [Medline].
Fujimoto M, Hamaguchi Y, Kaji K, Matsushita T, Ichimura Y, Kodera M, et al. Myositis-specific anti-155/140 autoantibodies target transcription intermediary factor 1 family proteins. Arthritis Rheum. 2012 Feb. 64(2):513-22. [Medline].
Sato S, Hirakata M, Kuwana M, Suwa A, Inada S, Mimori T, et al. Autoantibodies to a 140-kd polypeptide, CADM-140, in Japanese patients with clinically amyopathic dermatomyositis. Arthritis Rheum. 2005 May. 52(5):1571-6. [Medline].
Sato S, Hoshino K, Satoh T, Fujita T, Kawakami Y, Fujita T, et al. RNA helicase encoded by melanoma differentiation-associated gene 5 is a major autoantigen in patients with clinically amyopathic dermatomyositis: Association with rapidly progressive interstitial lung disease. Arthritis Rheum. 2009 Jul. 60(7):2193-200. [Medline].
Hoshino K, Muro Y, Sugiura K, Tomita Y, Nakashima R, Mimori T. Anti-MDA5 and anti-TIF1-gamma antibodies have clinical significance for patients with dermatomyositis. Rheumatology (Oxford). 2010 Sep. 49(9):1726-33. [Medline].
Chaisson NF, Paik J, Orbai AM, Casciola-Rosen L, Fiorentino D, Danoff S, et al. A novel dermato-pulmonary syndrome associated with MDA-5 antibodies: report of 2 cases and review of the literature. Medicine (Baltimore). 2012 Jul. 91(4):220-8. [Medline]. [Full Text].
Cuesta-Mateos C, Colom-Fernández B, Portero-Sainz I, Tejedor R, García-García C, Concha-Garzón MJ, et al. Autoantibodies against TIF-1-? and CADM-140 in Spanish patients with clinically amyopathic dermatomyositis (CADM): clinical significance and diagnostic utility. J Eur Acad Dermatol Venereol. 2014 Jul 28. [Medline].
Fiorentino D, Chung L, Zwerner J, Rosen A, Casciola-Rosen L. The mucocutaneous and systemic phenotype of dermatomyositis patients with antibodies to MDA5 (CADM-140): a retrospective study. J Am Acad Dermatol. 2011 Jul. 65(1):25-34. [Medline]. [Full Text].
Muro Y, Sugiura K, Hoshino K, Akiyama M. Disappearance of anti-MDA-5 autoantibodies in clinically amyopathic DM/interstitial lung disease during disease remission. Rheumatology (Oxford). 2012 May. 51(5):800-4. [Medline].
Tansley SL, Betteridge ZE, Gunawardena H, Jacques TS, Owens CM, Pilkington C, et al. Anti-MDA5 autoantibodies in juvenile dermatomyositis identify a distinct clinical phenotype: a prospective cohort study. Arthritis Res Ther. 2014 Jul 2. 16(4):R138. [Medline].
Smith ES, Hallman JR, DeLuca AM, Goldenberg G, Jorizzo JL, Sangueza OP. Dermatomyositis: a clinicopathological study of 40 patients. Am J Dermatopathol. 2009 Feb. 31(1):61-7. [Medline].
Ang GC, Werth VP. Combination antimalarials in the treatment of cutaneous dermatomyositis: a retrospective study. Arch Dermatol. 2005 Jul. 141(7):855-9. [Medline].
Iorizzo LJ 3rd, Jorizzo JL. The treatment and prognosis of dermatomyositis: an updated review. J Am Acad Dermatol. 2008 Jul. 59(1):99-112. [Medline].
Chérin P. [Current therapy for polymyositis and dermatomyositis]. Rev Med Interne. 2008 Jun. 29 Spec No 2:9-14. [Medline].
Hengstman GJ, van den Hoogen FH, van Engelen BG. Treatment of the inflammatory myopathies: update and practical recommendations. Expert Opin Pharmacother. 2009 May. 10(7):1183-90. [Medline].
Choy EH, Hoogendijk JE, Lecky B, Winer JB. Immunosuppressant and immunomodulatory treatment for dermatomyositis and polymyositis. Cochrane Database Syst Rev. 2005 Jul 20. CD003643. [Medline].
Edge JC, Outland JD, Dempsey JR, Callen JP. Mycophenolate mofetil as an effective corticosteroid-sparing therapy for recalcitrant dermatomyositis. Arch Dermatol. 2006 Jan. 142(1):65-9. [Medline].
Kasteler JS, Callen JP. Low-dose methotrexate administered weekly is an effective corticosteroid-sparing agent for the treatment of the cutaneous manifestations of dermatomyositis. J Am Acad Dermatol. 1997 Jan. 36(1):67-71. [Medline].
Villalba L, Hicks JE, Adams EM, et al. Treatment of refractory myositis: a randomized crossover study of two new cytotoxic regimens. Arthritis Rheum. 1998 Mar. 41(3):392-9. [Medline].
Boswell JS, Costner MI. Leflunomide as adjuvant treatment of dermatomyositis. J Am Acad Dermatol. 2008 Mar. 58(3):403-6. [Medline].
Newman ED, Scott DW. The Use of Low-dose Oral Methotrexate in the Treatment of Polymyositis and Dermatomyositis. J Clin Rheumatol. 1995 Apr. 1(2):99-102. [Medline].
Bunch TW. Prednisone and azathioprine for polymyositis: long-term followup. Arthritis Rheum. 1981 Jan. 24(1):45-8. [Medline].
Dalakas MC, Illa I, Dambrosia JM, et al. A controlled trial of high-dose intravenous immune globulin infusions as treatment for dermatomyositis. N Engl J Med. 1993 Dec 30. 329(27):1993-2000. [Medline].
Danieli MG, Calcabrini L, Calabrese V, Marchetti A, Logullo F, Gabrielli A. Intravenous immunoglobulin as add on treatment with mycophenolate mofetil in severe myositis. Autoimmun Rev. 2009 Dec. 9(2):124-7. [Medline].
Marie I, Menard JF, Hatron PY, et al. Intravenous immunoglobulins for steroid-refractory esophageal involvement related to polymyositis and dermatomyositis: a series of 73 patients. Arthritis Care Res (Hoboken). 2010 Dec. 62(12):1748-55. [Medline].
Oddis CV, Reed AM, Aggarwal R, Rider LG, Ascherman DP, Levesque MC, et al. Rituximab in the treatment of refractory adult and juvenile dermatomyositis and adult polymyositis: a randomized, placebo-phase trial. Arthritis Rheum. 2013 Feb. 65(2):314-24. [Medline]. [Full Text].
Aggarwal R, Bandos A, Reed AM, Ascherman DP, Barohn RJ, Feldman BM, et al. Predictors of clinical improvement in rituximab-treated refractory adult and juvenile dermatomyositis and adult polymyositis. Arthritis Rheumatol. 2014 Mar. 66(3):740-9. [Medline]. [Full Text].
Ge Y, Zhou H, Shi J, Ye B, Peng Q, Lu X, et al. The efficacy of tacrolimus in patients with refractory dermatomyositis/polymyositis: a systematic review. Clin Rheumatol. 2015 Sep 2. [Medline].
Pelle MT, Callen JP. Adverse cutaneous reactions to hydroxychloroquine are more common in patients with dermatomyositis than in patients with cutaneous lupus erythematosus. Arch Dermatol. 2002 Sep. 138(9):1231-3; discussion 1233. [Medline].
Woo TY, Callen JP, Voorhees JJ, et al. Cutaneous lesions of dermatomyositis are improved by hydroxychloroquine. J Am Acad Dermatol. 1984 Apr. 10(4):592-600. [Medline].
Zieglschmid-Adams ME, Pandya AG, Cohen SB, Sontheimer RD. Treatment of dermatomyositis with methotrexate. J Am Acad Dermatol. 1995 May. 32(5 Pt 1):754-7. [Medline].
Majithia V, Harisdangkul V. Mycophenolate mofetil (CellCept): an alternative therapy for autoimmune inflammatory myopathy. Rheumatology (Oxford). 2005 Mar. 44(3):386-9. [Medline].
Pisoni CN, Cuadrado MJ, Khamashta MA, Hughes GR, D'Cruz DP. Mycophenolate mofetil treatment in resistant myositis. Rheumatology (Oxford). 2007 Mar. 46(3):516-8. [Medline].
Rowin J, Amato AA, Deisher N, Cursio J, Meriggioli MN. Mycophenolate mofetil in dermatomyositis: is it safe?. Neurology. 2006 Apr 25. 66(8):1245-7. [Medline].
Waldman MA, Callen JP. Self-resolution of Epstein-Barr virus-associated B-cell lymphoma in a patient with dermatomyositis following withdrawal of mycophenolate mofetil and methotrexate. J Am Acad Dermatol. 2004 Aug. 51(2 Suppl):S124-30. [Medline].
Nadiminti U, Arbiser JL. Rapamycin (sirolimus) as a steroid-sparing agent in dermatomyositis. J Am Acad Dermatol. 2005 Feb. 52(2 Suppl 1):17-9. [Medline].
Cohen JB. Cutaneous involvement of dermatomyositis can respond to Dapsone therapy. Int J Dermatol. 2002 Mar. 41(3):182-4. [Medline].
Shimojima Y, Ishii W, Kato T, Hoshi K, Matsuda M, Hashimoto T, et al. Intractable skin necrosis and interstitial pneumonia in amyopathic dermatomyositis, successfully treated with cyclosporin A. Intern Med. 2003 Dec. 42(12):1253-8. [Medline].
Kampylafka EI, Kosmidis ML, Panagiotakos DB, Dalakas M, Moutsopoulos HM, Tzioufas AG. The effect of intravenous immunoglobulin (IVIG) treatment on patients with dermatomyositis: a 4-year follow-up study. Clin Exp Rheumatol. 2012 May-Jun. 30(3):397-401. [Medline].
Danieli MG, Moretti R, Gambini S, Paolini L, Gabrielli A. Open-label study on treatment with 20 % subcutaneous IgG administration in polymyositis and dermatomyositis. Clin Rheumatol. 2014 Apr. 33(4):531-6. [Medline].
Oliveri MB, Palermo R, Mautalen C, Hübscher O. Regression of calcinosis during diltiazem treatment in juvenile dermatomyositis. J Rheumatol. 1996 Dec. 23(12):2152-5. [Medline].
Ambler GR, Chaitow J, Rogers M, McDonald DW, Ouvrier RA. Rapid improvement of calcinosis in juvenile dermatomyositis with alendronate therapy. J Rheumatol. 2005 Sep. 32(9):1837-9. [Medline].
Slimani S, Abdessemed A, Haddouche A, Ladjouze-Rezig A. Complete resolution of universal calcinosis in a patient with juvenile dermatomyositis using pamidronate. Joint Bone Spine. 2010 Jan. 77(1):70-2. [Medline].
Balin SJ, Wetter DA, Andersen LK, Davis MD. Calcinosis cutis occurring in association with autoimmune connective tissue disease: the Mayo Clinic experience with 78 patients, 1996-2009. Arch Dermatol. 2012 Apr. 148(4):455-62. [Medline].
Alemo Munters L, Dastmalchi M, Andgren V, Emilson C, Bergegård J, Regardt M, et al. Improvement in health and possible reduction in disease activity using endurance exercise in patients with established polymyositis and dermatomyositis: a multicenter randomized controlled trial with a 1-year open extension followup. Arthritis Care Res (Hoboken). 2013 Dec. 65(12):1959-68. [Medline].
Alexanderson H, Munters LA, Dastmalchi M, Loell I, Heimbürger M, Opava CH, et al. Resistive home exercise in patients with recent-onset polymyositis and dermatomyositis -- a randomized controlled single-blinded study with a 2-year followup. J Rheumatol. 2014 Jun. 41(6):1124-32. [Medline].
Anyanwu CO, Fiorentino DF, Chung L, Dzuong C, Wang Y, Okawa J, et al. Validation of the Cutaneous Dermatomyositis Disease Area and Severity Index: characterizing disease severity and assessing responsiveness to clinical change. Br J Dermatol. 2015 Oct. 173 (4):969-74. [Medline].
Klein RQ, Bangert CA, Costner M, et al. Comparison of the reliability and validity of outcome instruments for cutaneous dermatomyositis. Br J Dermatol. 2008 Sep. 159(4):887-94. [Medline]. [Full Text].
Di Rollo D, Abeni D, Tracanna M, Capo A, Amerio P. Cancer risk in dermatomyositis: a systematic review of the literature. G Ital Dermatol Venereol. 2014 Jun 30. [Medline].
Metzger AL, Bohan A, Goldberg LS, Bluestone R, Pearson CM. Polymyositis and dermatomyositis: combined methotrexate and corticosteroid therapy. Ann Intern Med. 1974 Aug. 81(2):182-9. [Medline].
Marie I, Hachulla E, Hatron PY, Hellot MF, Levesque H, Devulder B, et al. Polymyositis and dermatomyositis: short term and longterm outcome, and predictive factors of prognosis. J Rheumatol. 2001 Oct. 28(10):2230-7. [Medline].
Efthimiou P, Schwartzman S, Kagen LJ. Possible role for tumour necrosis factor inhibitors in the treatment of resistant dermatomyositis and polymyositis: a retrospective study of eight patients. Ann Rheum Dis. 2006 Sep. 65(9):1233-6. [Medline]. [Full Text].
Iannone F, Scioscia C, Falappone PC, Covelli M, Lapadula G. Use of etanercept in the treatment of dermatomyositis: a case series. J Rheumatol. 2006 Sep. 33(9):1802-4. [Medline].
Dastmalchi M, Grundtman C, Alexanderson H, Mavragani CP, Einarsdottir H, Helmers SB, et al. A high incidence of disease flares in an open pilot study of infliximab in patients with refractory inflammatory myopathies. Ann Rheum Dis. 2008 Dec. 67(12):1670-7. [Medline].
Hengstman GJ, De Bleecker JL, Feist E, Vissing J, Denton CP, Manoussakis MN, et al. Open-label trial of anti-TNF-alpha in dermato- and polymyositis treated concomitantly with methotrexate. Eur Neurol. 2008. 59(3-4):159-63. [Medline].
Liu SW, Velez NF, Lam C, Femia A, Granter SR, Townsend HB, et al. Dermatomyositis induced by anti-tumor necrosis factor in a patient with juvenile idiopathic arthritis. JAMA Dermatol. 2013 Oct. 149(10):1204-8. [Medline].
Fathi M, Vikgren J, Boijsen M, Tylen U, Jorfeldt L, Tornling G, et al. Interstitial lung disease in polymyositis and dermatomyositis: longitudinal evaluation by pulmonary function and radiology. Arthritis Rheum. 2008 May 15. 59(5):677-85. [Medline].
Linos E, Fiorentino D, Lingala B, Krishnan E, Chung L. Atherosclerotic cardiovascular disease and dermatomyositis: an analysis of the Nationwide Inpatient Sample survey. Arthritis Res Ther. 2013 Jan 8. 15(1):R7. [Medline].
Carruthers EC, Choi HK, Sayre EC, Aviña-Zubieta JA. Risk of deep venous thrombosis and pulmonary embolism in individuals with polymyositis and dermatomyositis: a general population-based study. Ann Rheum Dis. 2014 Sep 5. [Medline].
Shimojima Y, Ishii W, Matsuda M, Tazawa K, Ikeda S. Coadministration of tacrolimus with corticosteroid accelerates recovery in refractory patients with polymyositis/ dermatomyositis: a retrospective study. BMC Musculoskelet Disord. 2012 Nov 22. 13:228. [Medline].