The Holster Sign: An Overlooked Cutaneous Finding in the Diagnosis of Dermatomyositis

Objective: Characteristic skin findings in dermatomyositis (DM) include Gottron’s papules (Gp), heliotrope rash (He) and shawl or V (S/V) sign. Noted in dermatology publications is a violaceous rash over the lateral hip, called the “Holster sign.” Our objective was to determine the incidence of the Holster sign (HS) in comparison to other DM cutaneous signs and to raise rheumatologists’ awareness of the HS. Methods: Patients with ICD-9 codes for DM, PM, MCTD and SS were identified. Patients received a survey that included pictures of He, Gp, S/V and HS and were asked to check if they “had any of the following skin findings?” Charts were reviewed to confirm the diagnosis and providers’ description of skin findings. We calculated the incidence rate, sensitivity and specificity of each skin sign for DM. Results: From 117 surveys, positive HS self-reporting was 22/28 in DM, 2/13 in PM, 0/21 in MCTD, and 6/55 in SS. Hs positive reporting of 78.5% in DM, was comparable to S/V (75%), Gp (85%), and He (71%). When compared to other signs, HS reporting was lowest in PM, MCTD and SS patients. Of all the skin signs, the HS had the highest specificity for DM (91%, range 75-91% for other signs) and comparable sensitivity (79%) to other signs (71-85%). Conclusion: This survey indicates that the HS has a comparable incidence to the more established and recognized cutaneous findings in DM. Based on these findings, we recommend looking for the HS sign in all patients with suspected DM.