Hydroxychloroquine alone insufficient to manage dermatomyositis
SAN DIEGO — Although patients with dermatomyositis are often advised to use adequate sun protection and prescribed similar therapies as patients with cutaneous lupus, the impact of hydroxychloroquine differs significantly between these two groups, according to a presentation at the 2019 Congress of Clinical Rheumatology West.
“The reason hydroxychloroquine has been considered a ‘first-line’ therapy for cutaneous dermatomyositis for years is essentially because it is a ‘first-line’ therapy for skin disease in lupus,” Ruth Ann Vleugels, MD, MPH, director of the Autoimmune Skin Disease Program at Brigham and Women’s Hospital, told attendees. “However, this does not mean it is actually the best ‘first-line’ agent for this disease.”
According to Vleugels, Pelle and colleagues reported that in a small cohort of 39 patients with dermatomyositis, 12 (31%) developed a cutaneous reaction associated with hydroxychloroquine use compared with only one patient among an age-, sex- and race-matched cohort of patients with cutaneous lupus erythematosus.
“Only one of the lupus patients got a drug rash from hydroxychloroquine while one-third of the dermatomyositis patients developed a cutaneous reaction to hydroxychloroquine,” Vleugels said. “This doesn’t mean that you don’t use hydroxychloroquine, but give your patients a pre-treatment warning: ‘If you get a new rash in the next few weeks, let me know — It would usually start on the trunk and then spread to your extremities.’”
She also noted that “if you keep these patients on the hydroxychloroquine, the dermatomyositis rash will actually flare in the context of that rash. You can get significant drug eruptions from hydroxychloroquine in dermatomyositis.”
In her own study of 114 patients with clinically amyopathic dermatomyositis from four tertiary care centers, Vleugels reported similar findings to Pelle and colleagues: “About one-third of our patients got a drug rash to hydroxychloroquine.” Additionally, although antimalarials were the most commonly used treatment type, the therapy was insufficient for disease control in 90% of patients.
“Even though almost all of these patients had been given antimalarials, only 10% did not need more aggressive therapy, specifically for their skin disease,” Vleugels said. “That has really changed how I think about my patients.”
“If someone comes in with moderate-to-severe dermatomyositis on their skin, I don’t just start hydroxychloroquine alone,” she added. “It is not going to be sufficient and you are going to waste 3 months waiting for it to kick in and miraculously fix their skin disease. Instead, although I may start hydroxychloroquine, I will start another agent as well – typically methotrexate or mycophenolate.” —by Robert Stott
- Vleugels RA. Clinical pearls from the dermatology-rheumatology clinics. Presented at: Congress of Clinical Rheumatology West; September 26-29, 2019; San Diego.
- Pelle MT et al. Arch Dermatol. 2002; doi:10.1001/archderm.138.9.1231.
- Pinard J et al. JAMA Dermatol. 2019; doi:10.1001/jamadermatol.2018.5215.
Disclosure: Vleugels reports a consulting relationship with Pfizer.