What is the first-line pharmacologic therapy for dermatomyositis?

• A. Methotrexate
• B. Azathioprine
• C. IV Immunoglobulin
• D. High-dose corticosteroids

Answer: (D)

High-dose systemic corticosteroids are used first because they rapidly suppress the autoimmune inflammation driving dermatomyositis, leading to quicker improvement in proximal muscle weakness and skin findings. Starting at about 1 mg/kg per day of prednisone (with IV methylpredsuffix for severe cases) induces remission more quickly than other agents. Once strength and enzymes improve, the dose is slowly tapered over months while watching for relapse and treating side effects.

Steroid-sparing options like methotrexate or azathioprine are added when long-term steroid exposure is a concern or if disease remains active, to maintain remission and allow further tapering. IV immunoglobulin is generally reserved for refractory cases or severe manifestations (such as significant dysphagia) after or alongside other therapies.