Dermatology: Practical and Conceptual Image Letter | Dermatol Pract Concept. 2023;13(2):e2023111 1 Violaceous Macules on the Auricles: a Clinical Sign of Dermatomyositis Lluís Corbella-Bagot1, Francesc Alamon-Reig1, Daniel Morgado-Carrasco1 1 Department of Dermatology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain Citation: Corbella-Bagot L, Alamon-Reig F, Morgado-Carrasco D. Violaceous Macules on the Auricles: A Clinical Sign of Dermatomyositis. Dermatol Pract Concept. 2023;13(2):e2023111. DOI: https://doi.org/10.5826/dpc.1302a111 Accepted: October 26, 2022; Published: April 2023 Copyright: ©2023 Corbella-Bagot et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Daniel Morgado-Carrasco, Dermatology Department, Hospital Clínic de Barcelona, C/ Villarroel, 170, 08036, Barcelona, Spain. Tel: (+34) 93 227 54 00; Fax: (+34) 932275438 E-mail: morgadodaniel8@gmail.com Case Presentation A 66-year-old male with a recently diagnosed metastatic bladder carcinoma presented with muscle weakness and generalized pruritic rash. Physical examination revealed he- liotrope erythema, V-neck sign, shawl sign, Gottron papules and dilated nailfold capillary loops. Interestingly, several purpuric macules, together with ulcers and crusting were ob- served in both auricles (Figure 1). Blood tests showed high muscle enzymes (creatine-kinase 5954 U/l [normal value <300 U/l] and aldolase 43.5 U/l [normal range 0.3-6.0 U/l]), and anti-transcriptional intermediary factor 1 gamma (TIF1-γ) antibody positivity. The remaining myositis-specific antibodies were negative. Skin and muscle biopsies confirmed the diag- nosis of dermatomyositis. Treatment with prednisone 120 mg/ day (1 mg/kg/day) and hydroxychloroquine 400 mg/day was initiated with progressive improvement of muscle weakness and cutaneous involvement. The patient also started chemo- therapy with gemcitabine and cisplatin and is currently under follow-up in the Oncology and Dermatology departments. Teaching Point Dermatomyositis can present with a myriad of cutaneous manifestations. Violaceous macules on the ears have recently been described in anti-melanoma differentiation-associated gene 5 (MDA-5) dermatomyositis and may correlate with a poor prognosis [1]. As the violaceous macules and ul- cers are predominantly located in anatomic protuber- ances in the auricle, a pressure-induced microangiopathy has been proposed as the pathogenic mechanism [2]. We have not found any described case presenting with positive anti-TIF1-γ antibodies, which have been associated with malignancies. We report a case of a paraneoplastic anti-TIF1-γ posi- tive dermatomyositis presenting with violaceous macules in both auricles. Clinicians should be aware of this recently described clinical sign since it may be related to a poor prognosis. A written consent form signed by the patient has been obtained. 2 Image Letter | Dermatol Pract Concept. 2023;13(2):e2023111 References 1. Intapiboon P, Siripaitoon B. Erythematous auricular papules in the fatal cases of anti-MDA5 antibody-positive interstitial lung disease. Respir Med Case Rep. 2020;19;31:101299. DOI: 10.1016/j.rmcr.2020.101299. PMID: 33294359. PMCID: PMC7695884. 2. Okiyama N, Inoue S, Saito A. et al. Antihelix/helix viola- ceous macules in Japanese patients with anti-melanoma differentiation-associated protein 5 (MDA5) antibody-associated dermatomyositis. Br J Dermatol. 2019;180(5):1226-1227. DOI: 10.1111/bjd.17431. PMID: 30431155. Figure 1. (A, B) Violaceous macules, crusting and ulcers on both auricles. The lesions are more evident in anatomical protuberances such as the helix and antihelix.