Several steroid-sparing agents such as methotrexate and cyclosporine are being prescribed by clinicians for dermomyositis but with little published evidence to support effectiveness. Methotrexate is an option for those who do not respond to prednisone or are in need of a steroid-sparing agent secondary to side effects (SOR: C).2,3 A suggested regimen starts with 7.5 to 10 mg/wk, then increases the dose to 2.5 mg/wk until reaching a total dose of 25 mg/wk. The dose of prednisone should be decreased as the methotrexate dose increases. Azathioprine is another option to consider along with methotrexate, but choosing one agent over another or a combination of 2 agents remains empirical. With any of the immunosuppressants or immunomodulatory agents, it is important to look at their side-effect profiles and monitor the patient accordingly.
After initiating treatment, look for evidence of malignancy among those patients older than 50 years so as not to miss an underlying cancer as the cause for their dermatomyositis. For women without any risk factors, a complete annual physical exam—including pelvic, breast, and rectal exam—is sufficient.2 It is not necessary to order expensive radiological studies blindly searching for malignancy, especially more than 2 years after the diagnosis is made. The greatest risk of malignancy occurs during the first year after diagnosis with a six-fold increase.1 The risk drops during the second year and a patient’s risk for malignancy is comparable to the normal population in the years following. A mammogram and colonoscopy might be indicated after considering the patient’s age and family history.
The patient’s treatment and outcome
The patient was started on 60 mg of oral prednisone, taken in a single daily dose. She also began physical therapy twice a week in order to prevent muscle atrophy and maximize function. She took the prednisone for 1 month, at which time her creatine kinase level was trending towards normal. We then began slowly tapering the prednisone over the next 6 months.
She reported improvement in her strength 3 months after starting the systemic steroids. Little improvement was seen in the patient’s skin while on systemic steroids, but after prescribing 0.1% triamcinolone ointment, recommending a broad-spectrum sunscreen, and limiting sun exposure, the patient reported less erythema and edema.
CORRESPONDING AUTHOR
Richard P. Usatine, MD, University of Texas Health Science Center at San Antonio, Department of Family and Community Medicine, MC 7794, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900. E-mail: usatine@uthscsa.edu