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Treatments and drugs
By Mayo Clinic staffThere's no cure for dermatomyositis, but treatment can improve your skin and your muscle strength and function. The earlier treatment is started in the course of dermatomyositis, the more effective it is, leading to fewer complications.
However, as with many conditions, no single approach is best; your doctor will tailor your treatment strategy based on your symptoms and how well they respond to therapy.
Corticosteroids
For most people, the first step in treatment for dermatomyositis is to take a corticosteroid medication. Usually for dermatomyositis, the chosen medication is prednisone.
Corticosteroids are medications that suppress your immune system, limiting the production of antibodies and reducing muscle inflammation, as well as improving muscle strength and function. Your doctor may also prescribe topical corticosteroids for your skin.
Your doctor may prescribe a high dose to begin with, and then decrease it as your signs and symptoms improve. Improvement generally takes about two to four weeks, but you may take the medication for several months. Prolonged use of corticosteroids can have serious and wide-ranging side effects, which is why your doctor may gradually taper the dose of medication down to low levels.
Because of the potential for serious side effects, your doctor may recommend supplements to combat them, such as calcium and vitamin D.
Additional immunosuppressive therapies
If a corticosteroid medication doesn't seem to be working effectively in your case, as a secondary approach your doctor may recommend that you add or switch to another medication:
- Corticosteroid-sparing agents. When used in combination with a corticosteroid, a corticosteroid-sparing medication can decrease the dose and potential side effects of the corticosteroid. These medications include azathioprine (Azasan, Imuran) or methotrexate (Trexall, Methotrexate, Rheumatrex). Your doctor may prescribe azathioprine or methotrexate initially along with prednisone if your disease is very progressive or if you have complicating factors. Some doctors prescribe these medications as a first line treatment for people in whom corticosteroids aren't recommended.
- Intravenous immunoglobulin (IVIG). IVIG is a purified blood product that contains healthy antibodies from thousands of blood donors. The healthy antibodies in IVIG can block the damaging antibodies that attack muscle and skin in dermatomyositis. This treatment is given as an infusion through a vein. The effects of IVIG are beneficial but don't last very long. Repeat infusions every six to eight weeks are often necessary.
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Other immunosuppressive medicine. Tacrolimus (Prograf) is a transplant-rejection drug that may work to inhibit the immune system. Tacrolimus is often used topically to treat dermatomyositis and other skin problems. When taken orally, it may be helpful in treating people who have dermatomyositis complicated by interstitial lung disease.
Immunosuppressants, such as cyclophosphamide (Cytoxan) and cyclosporine (Gengraf, Neoral, Sandimmune), may improve signs and symptoms of dermatomyositis and interstitial lung disease.
Biological therapies
If your case is severe and other treatment options have failed, your doctor may recommend one of these investigational medications as a third line approach to treating dermatomyositis:
- Rituximab (Rituxan) has been studied in small numbers of people with polymyositis and dermatomyositis and shown to improve muscle strength, lung involvement and skin rash.
- Tumor necrosis factor (TNF) inhibitors, such as etanercept (Enbrel) and infliximab (Remicade), are medicines that target key proteins associated with inflammation.
However, there aren't many scientific studies to date about the effectiveness of these agents on dermatomyositis. If your doctor prescribes one of these medications, he or she will closely monitor you to make sure the medication is working and to check for side effects. These medications can be expensive and, because they're experimental for treating dermatomyositis, may not be covered by insurance.
Other treatment approaches
Other treatment options your doctor might recommend include:
- Antimalarial medications. For a persistent rash, your doctor may prescribe an antimalarial medication, such as hydroxychloroquine (Plaquenil) or chloroquine (Aralen).
- Pain relievers. Over-the-counter drugs such as aspirin, ibuprofen (Advil, Motrin, others) and acetaminophen (Tylenol, others) can be used to treat pain. If these aren't sufficient, your doctor may prescribe a stronger pain reliever, such as codeine.
- Physical therapy. A physical therapist can show you exercises to maintain and improve your strength and flexibility and advise an appropriate level of activity.
- Speech therapy. If your swallowing muscles are weakened by dermatomyositis, speech therapy can help you learn how to compensate for those changes.
- Dietetic assessment. Later in the course of dermatomyositis, chewing and swallowing can become more difficult. A registered dietitian can teach you how to prepare easy-to-eat foods.
- Surgery. Surgery may be an option to remove painful calcium deposits and prevent recurrent skin infections.
- NINDS dermatomyositis information page. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/dermatomyositis/dermatomyositis.htm. Accessed June 13, 2011.
- Dalakas MC. Inflammatory disorders of muscle: Progress in polymyositis, dermatomyositis and inclusion body myositis. Current Opinion in Neurology. 2004;17:561.
- Miller ML. Clinical manifestations and diagnosis of adult dermatomyositis and polymyositis. http://www.uptodate.com/home/index.html. Accessed June 1, 2011.
- Greenberg SA, et al. Uncertainties in the pathogenesis of adult dermatomyositis. Current Opinion in Neurology. 2004;17:359.
- Santmyire-Rosenberger B, et al. Skin involvement in dermatomyositis. Current Opinion in Rheumatology. 2003;15:714.
- Baer AN, et al. Polymyositis & dermatomyositis. In: Imboden JB, et al. Current Rheumatology Diagnosis & Treatment. 2nd ed. New York, N.Y.: The McGraw-Hill Companies; 2007. http://www.accessmedicine.com/content.aspx?aid=2726184. Accessed June 6, 2011.
- Cordeiro AC, et al. Treatment of inflammatory myopathies. Postgraduate Medical Journal. 2006;82:417.
- Walker UA. Imaging tools for the clinical assessment of idiopathic inflammatory myositis. Current Opinion in Rheumatology. 2008;20:656.
- Miller ML, et al. Initial treatment of dermatomyositis and polymyositis in adults. http://www.uptodate.com/home/index.html. Accessed June 1, 2011.
- Miller ML, et al. Treatment of recurrent and resistant dermatomyositis and polymyositis in adults. http://www.uptodate.com/home/index.html. Accessed June 1, 2011.
- Dimachkie MM. Idiopathic inflammatory myopathies. Journal of Neuroimmunology. 2011;231:32.
- Koski CL, et al. Intravenous immunoglobulin use for neurologic diseases. Journal of Infusion Nursing. 2006;29:S21.
- Medications. The Myositis Association. http://www.myositis.org/template/page.cfm?id=304. Accessed June 9, 2011.
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