M.C. Tran,, M. Manahan,, E. McMeniman,
Flagellate erythema presents as erythematous, individual and intermingled, linear, striated streaks in a whiplashlike pattern. It is reported to be caused by antineoplastic agents (including bleomycin, Herceptin), toxins (from Shittake mushroom), rheumatologic diseases (dermatomyositis (DM), systemic lupus erythematosus) and pruritus-related dermatoses. Less commonly reported triggers include viral infections (parvovirus B19, Chikungunya), organismsrelated stings and inﬂiction-associated .
There are only approximately 16 cases published associated with DM. We report a case of a 36 year-old-female who presented with 6-week history of pruritic erythematous rash of face, torso, and upper limbs; delayed onset of generalised muscle weakness and myalgias, associated dyspnoea and dysphagia. Initially referred via our teledermatology services, on full skin review with dermatology was noted to have striking ﬂagellate erythema to neck, Vdistribution to chest, abdomen, back, forearms and dorsal hands, with poikilodermatous changes; facial malar erythema, and heliotrope. Her hands exhibited violaceous erythematous papules distributed over the metacarpophalangeal and interphalangeal joints (Gottron’s papules), and periungal telengiectasiae.
Laboratory analysis showed an elevated creatinine kinase of 1050 U/L. Immunological investigations showed antinuclear antibodies were positive in a speckled pattern (titer 1:640). Other rheumatologic antibodies (dsDNA, ENA screen) were negative. A myositis antibody proﬁle revealed PL12 positivity and equivocal TIF1-gamma. Skin lesions and muscle biopsies conﬁrmed DM. Investigations for underlying malignancy have been negative to date.
Flagellate erythema is not known to be associated with speciﬁc subtypes of DM and no known increased risk of malignancy or a poorer prognosis. She was successfully treated with a combination of oral prednisone, methotrexate and hydroxychloroquine.