Flagellate erythema in transcription intermediary factor 1 gamma dermatomyositis

A 52-year-old Chinese woman was diagnosed with transcription intermediary factor 1 (TIF1) gamma dermatomyositis in November 2022, with manifestations of myositis, polyarthralgia, and low-grade fever. She had cutaneous manifestations of Gottron's sign, V-neck sign, shawl sign, and flagellate erythema (Figure 1A). No interstitial lung disease was detected by high-resolution computed tomography. Comprehensive malignancy screenings, encompassing pap smear and mammogram, endoscopic examination, and computed tomography scans of the thorax, abdomen, and pelvis, were performed. They returned negative, apart from a lobulated nodule with biopsy confirmed as sclerosing pneumocytoma at the left lower lobe (Figure 1C). The therapeutic regimen, consisting of high-dose steroids and mycophenolate mofetil, effectively ameliorated the patient's myositis and rash (Figure 1B). The typical cutaneous manifestations of dermatomyositis include Gottron's sign and papules, heliotrope rash, periungual erythema, V-neck sign, and shawl sign. Rarely, flagellate erythema is seen as a skin manifestation of dermatomyositis, occurring in 5% of patients with idiopathic dermatomyositis.1 Flagellate erythema is characterized by linear erythematous streaks, simulating the marks of whiplashes, and is found mainly on the trunk. Such manifestations have been observed as side effects of chemotherapy drugs like bleomycin, dermatitis from ingestion of shiitake mushrooms, and less commonly in adult-onset Still's disease and dermatomyositis.2 Previously, some authors reported an association between the presence of flagellate erythema in dermatomyositis and malignancy, with 38% of previously reported cases of dermatomyositis-associated flagellate erythema having concurrent malignancies.3, 4 However, this does not seem to be the case for this patient. This is despite the fact that this patient tested positive for TIF1 gamma antibodies, as TIF1 gamma-positive dermatomyositis is strongly associated with an increased risk of malignancy.5 This is a rare cutaneous manifestation of dermatomyositis that physicians should be aware of, and it represents one of the diverse cutaneous manifestations associated with dermatomyositis. Chuanhui Xu contributed to the provision of the case. Both authors were involved in drafting the manuscript and the final approval of the manuscript. The authors are grateful to the patient for allowing the publishing of her case. The authors declare no conflicts of interest. Informed consent was provided by the patient. The data used in this article are available from the corresponding author upon reasonable request.