Dr. Jennie Clarke discusses pearls from her lecture " Dermatomyositis: How I Do It" on Saturday, November 11, 2023, at the 4th Annual Elevate-Derm PA/NP Conference in Coachella Valley, CA.

In this video

In conversation with PA Eileen Cheever, Dr. Clarke explains that the clinical physical exam is "absolutely the most critical part" of diagnosing dermatomyositis. She wants patients in a gown for a thorough head-to-toe look, from the scalp — where findings can first mimic psoriasis — down to the toes, hunting for the heliotrope rash, Gottron's papules, nail changes, and redness over the extensor surfaces of joints, especially in photo-distributed areas. Biopsy can help, she notes, "more often in ruling things out than ruling things in," and myositis antibody panels add another useful tool.

She stresses that roughly 20% of patients have amyopathic disease without muscle complaints, so it's essential to ask about muscle symptoms and check proximal strength — often just by having them rise from a chair without using their arms — as well as shortness of breath, since interstitial lung disease affects about 20% of patients. Once diagnosed, patients need a thorough malignancy workup (25–30% have an associated cancer), strict sun protection, and, because these are "tough patients to treat," frequently immunomodulating or immunosuppressive therapy chosen in close partnership with rheumatology.

  • The clinical skin exam drives the diagnosis: gown the patient and examine head to toe for heliotrope rash, Gottron's papules, nail changes, and extensor-surface redness in photo-distributed areas.
  • About 20% of patients have amyopathic dermatomyositis — always ask about muscle symptoms and check proximal strength (e.g., standing from a chair without arms) even when the skin is the only complaint.
  • Screen for interstitial lung disease by asking about shortness of breath, since it affects roughly 20% of patients.
  • Work every patient up for malignancy — 25–30% have an associated cancer that can involve any organ.
  • These are photosensitive, hard-to-treat patients; emphasize sun protection and partner closely with rheumatology to select immunomodulating or immunosuppressive therapy.