PMC5883386_01
Patient facial appearances before (A,C) and after (B,D) treatment.. 
A: Periorbital edema at presentation. The edema was evolving rapidly and the patient was unable to open his eyes.
B: Subsidence of edema was followed by extensive skin desquamation. Erythema is due to corticosteroid therapy.
C,D: Development of marked alopecia. Photographs B and D were taken on hospital day 26.
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On examination there was bilateral, sensitive to palpation, edema involving the eyelids, nose, malar areas, forehead and anterior part of the scalp, associated with painful cervical lymphadenopathy ( Figure 1A). Edema of face and scalp had completely subsided, leaving extensive desquamation and alopecia of involved areas ( Figure 1B-D).
Skin and muscle biopsy.. 
A, B: Myositis in the form of a mainly lymphocytic cellular infiltrate of striated muscle fibers with subsequent destruction and regeneration. (Hematoxylin and eosin x250, x400.)
C: Leukocytoclastic vasculitis (fibrinoid necrosis and nuclear dust) in septal vessels of the subcutaneous tissue. (Hematoxylin and eosin x400.)
D: Telangiectatic vessels in the reticular dermis, edema and a mild lymphocytic infiltrate. (Hematoxylin and eosin x200.)
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The muscle biopsy findings were typical of DM, while skin biopsy histology was compatible with, although not diagnostic of DM. ( Figure 2).