Dermatomyositis-like eruption following hydroxyurea therapy

Investigating the disparities among drug categories in drug-induced dermatomyositis: A systematic review

Drug-induced dermatomyositis (DIDM) is a rare and underestimated variant of dermatomyositis (DM) characterized by muscle damage and skin rash and related to certain drug exposure. The spectrum of drugs causing DIDM has evolved over time, originally implicating hydroxyurea, penicillamine, and statins as causative agents. Tumor necrosis factor α inhibitors and immune checkpoint inhibitors have also been associated with such conditions. To bridge the gap between current literature and clinical practice, and therefore guide clinicians, we conducted a comprehensive review of English literature from Pubmed, EMBASE, and MEDLINE. Our analysis included demographic data, clinical features, laboratory findings, therapeutic outcomes, and extant research pertaining to the probable pathogenesis of DIDM induced by various drugs. Furthermore, we categorized the drugs involved in DIDM cases into biologics and traditional agents for subsequent statistical analysis. Over time, there has been a gradual accumulation of reported DIDM cases. A total of 69 published DIDM cases were documented in our study, among which 33 should be attributed to biologics and the remaining 36 to traditional drugs. Interestingly, 41 of all DIDM cases had a previous history of malignancies. Additionally, DIDM cases exhibited similar cutaneous and muscular manifestations to classic DM, with the exception of cases induced by hydroxyurea, which did not entail muscle damage. Positive antinuclear antibodies and anti-TIF1-γ autoantibodies have been predominantly observed in biologics-induced cases, while positive anti-TIF1-γ antibodies were merely reported in the cases that were primarily diagnosed with malignant diseases and exposed to ICIs afterwards. Anti-TIF1-γ antibodies may potentially serve as a red flag in the identification of co-existing malignant diseases in DM patients. We also provided a comprehensive summary and exploration of potential mechanisms lying behind drug-induced dermatomyositis. In conclusion, our review consolidates the current literature on DIDM, highlighting the evolving spectrum of medications and elucidating the differences in clinical manifestations, laboratory findings, and underlying mechanisms.

Causes and Clinical Presentation of Drug-Induced Dermatomyositis: A Systematic Review

Importance

While several medications are known to induce dermatomyositis (DM), most existing studies are case reports or small case series from a single institution. There is also limited information on DM induced by immune checkpoint inhibitors, which are increasingly used in oncologic therapy.

Objective

To characterize causes and clinical presentation of drug-induced DM based on the current literature.

Evidence Review

A systematic review was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, from inception to August 22, 2022. Articles meeting preestablished inclusion criteria (written in English and classified as original articles, case reports, literature reviews, and observation letters) were selected and data abstracted. Articles that met the scope of the review were also added from reference lists. When possible, study results were quantitatively combined.

Findings

In 134 studies (114 from the literature search and 20 additional studies pulled from reference lists) describing 165 cases, 88 patients (53.3%) were female, and the median (IQR) age was 61 (49-69) years. Among the cases of drug-induced DM, the most common associated medications were hydroxyurea (50 [30.3%]), immune checkpoint inhibitors (27 [16.4%]), statins (22 [13.3%]), penicillamine (10 [6.1%]), and tumor necrosis factor inhibitors (10 [6.1%]). Histopathologic testing, when undertaken, helped establish the diagnosis. There was a median (IQR) of 60 (21-288) days between drug initiation and drug-induced DM onset. History of cancer was reported in 85 cases (51.6%).

Conclusions and Relevance

In this systematic review, drug-induced DM was associated with multiple types of medications, including chemotherapies and immunotherapies. It is essential that dermatologists promptly recognize and diagnose drug-induced DM so that they can guide management to minimize interruption of therapy when possible.

Hydroxyurea-induced dermatomyositis: true amyopathic dermatomyositis or dermatomyositis-like eruption?

BACKGROUND

  Hydroxyurea-induced dermatomyositis is a rare adverse reaction of long-term hydroxyurea therapy. It has been reported under different names; however, the exact classification and nomenclature of this eruption have been the subject of much debate, and a more precise term is still awaiting. Herein, we review the different aspects of this reaction and suggest a new term that might help to minimize the confusion about its nomenclature.

MATERIALS AND METHODS

We describe a 68-year-old woman who had been on long-term hydroxyurea therapy for the treatment of chronic myeloid leukemia for nine years. She presented with typical dermatomyositis-like lesions and many of the other mucocutaneous adverse effects of hydroxyurea.

RESULTS

Skin examination revealed typical Gottron's papules on the dorsa of the hands, atrophy, xerosis, acquired ichthyosis, photosensitivity, cutaneous, oral and nail hyperpigmentation, acral erythema, palmoplantar keratoderma, actinic keratoses, and leg ulcers. There was no clinical or laboratory evidence of proximal muscle weakness. Cessation of hydroxyurea was associated with remarkable improvement of the skin lesions.

CONCLUSION

Hydroxyurea-induced dermatomyositis is a rare drug-induced dermatomyositis characterized by skin lesions identical to classic dermatomyositis without clinical or laboratory evidence of myositis. We propose that the term hydroxyurea-induced amyopathic dermatomyositis that adequately describes the findings reported in this subset of patients would be more precise and specific.

Dermatomyositis induced by drug therapy: a review of case reports

BACKGROUND

Drugs have occasionally been implicated in dermatomyositis (DM) onset.

OBJECTIVE

We sought to review case reports of drug-induced DM.

METHODS

Articles were gathered from MEDLINE and bibliographies of acquired reports. Causality was assessed using World Health Organization criteria. Clinical characteristics, management, and resolution were examined.

RESULTS

In 70 reported cases, 50% of patients were female and the median age was 57 years. Hydroxyurea was implicated in 51% of cases. All cases had pathognomonic (76%) or compatible (24%) cutaneous findings. Hydroxyurea cases lacked myositis, but myositis was described in 79.4% of nonhydroxyurea cases. Drug causality was probable (25.7%) or possible (74.3%), but not certain in any case. Most patients had underlying pathology associated with DM (44% had malignancy; 16% had rheumatoid arthritis). Of the sample, 84.3% had improvement of DM after discontinuation of the drug.

LIMITATIONS

Case reports may emphasize unusual findings.

CONCLUSIONS

Further work is needed to differentiate drug effects from underlying, predisposing factors.

Dermatomyositis: an overview of recent progress with emphasis on dermatologic aspects

Important points regarding DM and C-ADM are as follows: C-ADM is a working functional designation for patients having the skin-only and skin-predominant subsets of DM, amyopathic DM, and hypomyopathic DM. C-ADM seems to have approximately 10% the incidence of classic DM in whites and possibly a higher incidence in Asians. Some patients who present with C-ADM, with or without subclinical laboratory abnormalities, can slowly progress to develop symptomatic muscle weakness over a period of years, whereas others go for 10 to 20 years and longer without the appearance of muscle weakness. C-ADM patients are at risk for potentially life-threatening complications of classic DM, such as interstitial lung disease, which may occur in up to 10% of C-ADM patients. This risk seems to be even greater in some ethnic subgroups (e.g., Japanese). C-ADM patients may also be at increased risk for internal malignancy and until further studies are carried out to confirm the statistical significance of this association, all such patients should have a thorough evaluation for internal malignancy, identical to the approach currently used in classic DM patients. Dermatologists are in the best position initially to diagnose C-ADM patients and can contribute greatly to their overall management and quality of life. Ongoing vigilance is required, however, for complications that can arise in C-ADM patients including potentially fatal interstitial lung disease, internal malignancy, delayed onset of muscle weakness from myositis, and complications of systemic drug therapy. Topical therapy with broad-spectrum sunscreens, anti-inflammatories, and antipruritics should be maximized during the initial management of the cutaneous manifestations of either classic DM or C-ADM. Single-agent or combined aminoquinoline antimalarial therapy represents the safest initial form of systemic therapy for DM-specific skin disease occurring in any clinical setting; however, this approach tends to be less effective in general than for cutaneous LE. There is a theoretical rationale for and limited preliminary successful anecdotal experience with the use of anti-TNF-alpha therapy in refractory cases of classic DM and C-ADM. Cautious systematic clinical trials in this area should be considered.