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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Dermatomyositis is an idiopathic inflammatory myopathy that usually progresses with inflammation of the skin and skeletal muscle&#46; However&#44; there are hypomyopathic and amyopathic forms that progress without laboratory abnormalities and&#47;or muscle weakness&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a> While the cause is not generally known&#44; some forms can be induced or exacerbated by drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> We report a case of dermatomyositis-like eruption with no muscle involvement associated with hydroxyurea and review specific immunological&#44; clinical&#44; and epidemiological findings&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 63-year-old woman diagnosed with essential thrombocytopenia who had been receiving treatment with hydroxyurea since 2010&#46; She was evaluated at the dermatology clinic for a 3-year history of erythematous&#44; scaly lesions on the dorsum of the interphalangeal and metacarpophalangeal joints of the hands&#44; dorsum of the feet&#44; elbows&#44; knees&#44; and presternal area &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; No muscular weakness or other remarkable cutaneous or mucosal manifestations were observed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The histopathology findings are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#46; The laboratory workup revealed normal results for inflammatory parameters and muscle enzymes&#46; Negative results were recorded for myositis-specific antibodies &#40;anti-Mi2&#44; anti-MDA5&#44; anti&#8211;SAE&#44; anti-TIF&#44; anti&#8211;NXP-2&#44; anti-t-RNA-synthetase&#44; anti&#8211;PMS&#44; anti&#8211;SSA&#47;Ro&#44; anti-U1RNP&#44; anti-Pm-Scl&#44; and anti-Ku&#41; and for antinuclear antibodies&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">On the basis of these findings&#44; the patient was diagnosed with dermatomyositis-like eruption secondary to treatment with hydroxyurea&#44; and&#44; given the hematology report&#44; we opted to suspend treatment&#46; The lesions were in remission at 3 months&#44; although the increased platelet count obliged us to reintroduce the medication&#44; thus exacerbating the lesions again&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Dermatomyositis secondary to drugs is an uncommon condition&#46; The drugs involved include hydroxyurea&#44; statins&#44; terbinafine&#44; and anti&#8211;tumor necrosis factor agents&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;4</span></a> With no distinctions between drugs&#44; the forms induced by medications carry a 39&#37; risk of muscle involvement&#44; which is lower than in the classic forms&#44; and up to 50&#37; of patients also have cancer or an underlying autoimmune disease&#46; Furthermore&#44; the disease usually affects patients taking multiple medications for their underlying condition&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> Consequently&#44; diagnosis is truly challenging for 2 reasons&#58; it is difficult to determine which drug is involved and it is complicated to determine whether dermatomyositis is related to the drug or to the underlying cancer or rheumatic disease&#46; In addition&#44; given that paraneoplastic dermatomyositis is amyopathic in almost 60&#37; of cases<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> and that muscle involvement in drug-related forms is uncommon&#44; the differential diagnosis is&#44; if anything&#44; somewhat more complex&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the first place&#44; it is important to know which drug is responsible&#46; Hydroxyurea is the most commonly involved drug &#40;50&#37; of cases&#41;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> and presents specific features with respect to other drugs&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> In clinical terms&#44; in addition to the typical cutaneous manifestations of classic dermatomyositis&#44; the presence of cutaneous-mucosal manifestations associated with hydroxyurea &#40;eg&#44; xerosis&#44; atrophy&#44; stomatitis&#44; ulceration&#44; and melanonychia&#41; is habitual&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#8211;5</span></a> Histopathology findings are indistinguishable from those found in classic dermatomyositis&#44; although&#44; in some cases&#44; there have been reports of changes suggestive of hydroxyurea-induced squamous dysplasia&#44; such as keratinocyte atypia and overexpression of p53&#46; According to some authors&#44; the condition carries a risk of progression to cutaneous squamous cell carcinoma&#44; which would require close follow-up of patients in the long term and withdrawal of the drug when dermatomyositis appears&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Immunosuppressive treatment is not usually necessary&#44; and suspension of hydroxyurea is generally sufficient to achieve remission of the clinical condition&#46; However&#44; immunosuppressive treatment is necessary in cases secondary to other drugs&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The second challenge is to determine whether the underlying neoplasm itself or a drug is responsible for the clinical condition&#46; This is especially difficult with hydroxyurea&#44; since it is not associated with muscle involvement and&#44; as we have already said&#44; paraneoplastic dermatomyositis is amyopathic in most cases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> The most indicative parameter for differentiating this condition seems to be the time between onset of dermatomyositis and diagnosis of the tumor&#46; Paraneoplastic symptoms generally appear during the first 2 years after diagnosis of the tumor&#44; especially during the first 7 months&#46; In the case of drug-associated cases&#44; only 37&#37; are diagnosed during the first 3 years&#44; whereas 78&#37; appear during the first 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> In the present case&#44; the interval was 40 months&#44; which is far from the mean time reported for paraneoplastic cases&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion&#44; dermatomyositis-like eruption associated with hydroxyurea is not a true myopathy for 2 reasons&#58; first&#44; it is not an immune-mediated condition&#44; as seen in the low frequency of antinuclear antibodies&#59; and second&#44; it is not associated with muscle weakness&#46; While the etiology is unknown&#44; some authors defend the presence of factors other than those of the drug itself&#44; such as the tumor in which the drug is used as treatment and the potential role of the interaction between UV radiation and hydroxyurea&#44; which could indicate a phototoxic reaction&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">4&#44;5</span></a> Similarly&#44; it is worth pointing out the risk of developing cutaneous squamous cell carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> Lastly&#44; it is important to distinguish the eruption from amyopathic paraneoplastic dermatomyositis owing to its better prognosis and different therapeutic management&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Moreno-Artero E&#44; Paricio JJ&#44; Anto&#241;anzas J&#44; Espa&#241;a A&#46; Erupci&#243;n dermatomiositis-<span class="elsevierStyleItalic">like</span> en una paciente tratada con hidroxiurea&#46; Actas Dermosifiliogr&#46; 2019&#59;110&#58;64&#8211;67&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#44; Periorbital heliotrope rash&#46; B&#44; Prominent periungual telangiectases&#46; C&#44; Erythematous&#44; scaly plaque on the knee&#46; D&#44; Erythematous&#44; scaly lesions on the dorsum of the interphalangeal and metacarpophalangeal joints&#46; E&#44; Erythematous&#44; scaly plaque on the buttocks&#46; F&#44; Erythematous&#44; scaly lesions on the dorsum and lateral aspect of the feet&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A and B&#44; Histopathology reveals parakeratosis&#44; mild epidermal atrophy&#44; lymphocytic exocytosis&#44; and foci of vacuolization in the basement layer&#44; with occasional apoptotic keratinocytes &#40;hematoxylin-eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>4&#44;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; C&#44; Vascular proliferation and mild fibrosis in the dermis&#46; No keratinocyte atypia or overexpression of p53 is observed &#40;hematoxylin-eosin&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>20&#41;&#46; D&#44; Abundant interstitial acid mucin deposits can be observed &#40;colloidal iron&#44; original magnification<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; ANA&#44; antinuclear antibodies&#59; DM&#44; dermatomyositis&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Seidler and Gottlieb&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hydroxyurea-Associated DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">DM Associated With Other Drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median age at diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median time since administration of drug until onset of DM&#44; mo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Positive ANA titer&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Muscular symptoms&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Underlying neoplasm&#44; &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suppression of the drug&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suppression of the drug<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>immunosuppressant&nbsp;\t\t\t\t\t\t\n
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