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Inverse Gottron’s papules and mechanic’s hands after a tug of war: triggered by friction and pressure?

Inverse Gottron’s papules and mechanic’s hands after a tug of war: triggered by friction and... A 31-year-old female presented with 4-week history of painful rashes on the hands. Six weeks ago, she had been involved in a tug of war, after which she experienced a burning sensation in her palms, followed by papules developing on her hands. On examination, hyperkeratotic, scaling, fissuring lesions (mechanic’s hands) were observed on her fingertips (Fig. 1A and B) and the lateral sides of her fingers (Fig. 1C). On the flexor aspects of the IP joints, tender, hyperkeratotic, dusky red papules were noted, most of which manifested as two separate papules on either side of the joint (Fig. 1D), consistent with inverse Gottron’s papules. Physical examination also showed Gottron’s papules over the elbow (Fig. 1E). She reported shortness of breath for 1 week and denied any muscle weakness. Fig. 1 Open in new tabDownload slide Clinical manifestations of the patient (A–C) Mechanic’s hands. (D) Aligned hyperkeratotic, palmar dusky red papules with a few areas of ulceration, referred to as inverse Gottron’s papules. (E) Erythematosous and fissured papules over the elbow. Laboratory analysis was notable for positive anti-melanoma differentiation-associated gene 5 (MDA5) antibodies. Serum creatine kinase, malignancy screen and electromyography were normal. Interstitial lung disease was confirmed in high-resolution computed tomography. A diagnosis of anti-MDA5 DM was thus made. She was managed with glucocorticoids and tacrolimus, with which her symptoms improved. Stretch and movement have been implicated in the pathogenesis of DM [1, 2], but do not receive much attention. In the present case, the strong temporal association and the distribution of papules suggested such movement as a precipitating factor. The minor injuries caused by the friction and pressure might act with, or result in, autoimmunity to promote new-onset DM in genetically susceptible individuals. Acknowledgements The patient in this manuscript has given written informed consent to publication of their case details, which we really appreciate. Funding: No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article. Disclosure statement: The authors have declared no conflicts of interest. Data availability statement Data are available upon reasonable request by any qualified researchers who engage in rigorous, independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). All data relevant to the study are included in the article. References 1 Kim JS , Bashir MM, Werth VP. Gottron’s papules exhibit dermal accumulation of CD44 variant 7 (CD44v7) and its binding partner osteopontin: a unique molecular signature . J Invest Dermatol 2012 ; 132 : 1825 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Kurtzman DJB , Ho A, Wright NA, Rubenstein MH, Vleugels RA. Unilateral Gottron papules in a patient following a stroke: clinical insights into the disease mechanisms and pathophysiology of cutaneous dermatomyositis . JAMA Dermatol 2016 ; 152 : 1062 – 3 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes * Hanlin Yin and Bei Liu contributed equally to this paper. © The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Rheumatology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Rheumatology Advances in Practice Oxford University Press

Inverse Gottron’s papules and mechanic’s hands after a tug of war: triggered by friction and pressure?

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Publisher
Oxford University Press
Copyright
Copyright © 2023 British Society for Rheumatology
eISSN
2514-1775
DOI
10.1093/rap/rkab103
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Abstract

A 31-year-old female presented with 4-week history of painful rashes on the hands. Six weeks ago, she had been involved in a tug of war, after which she experienced a burning sensation in her palms, followed by papules developing on her hands. On examination, hyperkeratotic, scaling, fissuring lesions (mechanic’s hands) were observed on her fingertips (Fig. 1A and B) and the lateral sides of her fingers (Fig. 1C). On the flexor aspects of the IP joints, tender, hyperkeratotic, dusky red papules were noted, most of which manifested as two separate papules on either side of the joint (Fig. 1D), consistent with inverse Gottron’s papules. Physical examination also showed Gottron’s papules over the elbow (Fig. 1E). She reported shortness of breath for 1 week and denied any muscle weakness. Fig. 1 Open in new tabDownload slide Clinical manifestations of the patient (A–C) Mechanic’s hands. (D) Aligned hyperkeratotic, palmar dusky red papules with a few areas of ulceration, referred to as inverse Gottron’s papules. (E) Erythematosous and fissured papules over the elbow. Laboratory analysis was notable for positive anti-melanoma differentiation-associated gene 5 (MDA5) antibodies. Serum creatine kinase, malignancy screen and electromyography were normal. Interstitial lung disease was confirmed in high-resolution computed tomography. A diagnosis of anti-MDA5 DM was thus made. She was managed with glucocorticoids and tacrolimus, with which her symptoms improved. Stretch and movement have been implicated in the pathogenesis of DM [1, 2], but do not receive much attention. In the present case, the strong temporal association and the distribution of papules suggested such movement as a precipitating factor. The minor injuries caused by the friction and pressure might act with, or result in, autoimmunity to promote new-onset DM in genetically susceptible individuals. Acknowledgements The patient in this manuscript has given written informed consent to publication of their case details, which we really appreciate. Funding: No specific funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out the work described in this article. Disclosure statement: The authors have declared no conflicts of interest. Data availability statement Data are available upon reasonable request by any qualified researchers who engage in rigorous, independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). All data relevant to the study are included in the article. References 1 Kim JS , Bashir MM, Werth VP. Gottron’s papules exhibit dermal accumulation of CD44 variant 7 (CD44v7) and its binding partner osteopontin: a unique molecular signature . J Invest Dermatol 2012 ; 132 : 1825 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Kurtzman DJB , Ho A, Wright NA, Rubenstein MH, Vleugels RA. Unilateral Gottron papules in a patient following a stroke: clinical insights into the disease mechanisms and pathophysiology of cutaneous dermatomyositis . JAMA Dermatol 2016 ; 152 : 1062 – 3 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes * Hanlin Yin and Bei Liu contributed equally to this paper. © The Author(s) 2021. Published by Oxford University Press on behalf of the British Society for Rheumatology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected]

Journal

Rheumatology Advances in Practice – Oxford University Press

Published: Jan 4, 2022

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