Clinical Images: Kissing papules in anti–melanoma differentiation–associated gene 5 antibody dermatomyositis

The patient, a 38-year-old Hispanic man of Black descent, was evaluated by rheumatology for a positive antinuclear antibodies test result. He reported skin lesions on his hands and elbows for several years. He reported no muscle weakness, joint pain, or shortness of breath. The skin examination was notable for diffuse, nonscarring alopecia; rough and hyperpigmented plaques; some healing pink atrophic plaques on the elbows and dorsal aspect of the knuckles (A) consistent with healed ulcerative Gottron lesions; and (B) painless hyperpigmented papules on the flexor surfaces on the fingers consistent with "kissing papules." High-resolution computed tomography of the chest showed scant bilateral peripheral cystic changes and trace bilateral dependent ground glass opacities of the lungs. A comprehensive metabolic panel and creatine kinase and aldolase levels were within reference limits. Ferritin level was elevated at 900 ng/mL (reference range: 30–330 ng/mL). A myositis-specific autoantibody (MSA) panel was ordered, given the concern for anti–melanoma differentiation–associated gene 5 antibody (MDA-5) dermatomyositis, and the patient was started on immunosuppression with systemic glucocorticoids and glucocorticoid-sparing agents. After three weeks, the MSA panel came back with a high-titer anti–MDA-5 antibody level. Because of insurance-related issues, the patient will be followed up by another rheumatologist. Kissing papules or "kissing ulcers" refers to papules or ulcers occurring in skin folds and forming symmetrical lesions on each side. It is one of the novel and unique cutaneous characteristics of anti–MDA-5 dermatomyositis. It can occur in the palms, axillae, antecubital fossae, and other skin folds. Early recognition of unique skin manifestations can help physicians initiate treatment—and hopefully improve outcomes—while awaiting an MSA panel.