Skin disorders and thyroid diseases

Skin Sceneries of Thyroid Disorders and Impact of Thyroid on Different Skin Diseases: A Scoping Review Focused on Pediatric Patients

Thyroid function plays a seminal role in the growth and development of children, and alterations in signaling pathways which interfere with the biosynthesis, transport, and metabolism of thyroid hormones might impact on the skin of such patients: this review explores the relationship between different thyroid disorders and dermatological manifestations with a particular focus on the pediatric population. Common cutaneous conditions associated with thyroid dysfunction may include chronic urticaria, vitiligo, and alopecia, which can be early harbingers of an underlying endocrine disruption. This review also highlights the growing cognizance of a "thyroid-skin axis", with thyroid hormones influencing many physiologic processes within the skin such as keratinocyte proliferation, hair growth, and epidermal differentiation. A precocious recognition of abnormal dermatological signs can be crucial in pediatric patients for a timely diagnosis before any development of complications and for personalized treatments of an underlying thyroid disorder, which can even be symptomless at an initial phase. Despite the lack of standardized guidelines for managing dermatologic manifestations occurring in thyroid diseases, a regular screening to identify endocrine dysfunction is recommended in those children who present chronic urticaria, vitiligo, or alopecia, though further research is needed to decipher mechanisms involved in the thyroid-skin partnership and develop more targeted management approaches.

Exploring the Metabolic and Endocrine Preconditioning Associated with Thyroid Disorders: Risk Assessment and Association with Acne Severity

Metabolic preconditioning, characterized by conditions like obesity and insulin resistance syndrome, disrupts hormonal balance. Elevated androgen levels stimulate excessive sebum production and follicular cell proliferation, leading to acne lesions. Similarly, thyroid hormone imbalances affect sebaceous gland activity, epidermal lipid composition, and skin cell turnover, impacting acne occurrence and severity. This study aimed to assess the potential contribution of metabolic and endocrine preconditions to acne development. A total of 389 patients diagnosed with acne were included and divided into three groups: the metabolic precondition group (MPG, N = 163, 41.9%), the endocrine precondition group (EPG, N = 162, 41.65%), and the control group (CG, N = 89, 22.88%). Data related to the degree of acne severity and comorbidities of interest were collected from the patients' medical records. In the groups with concomitant diseases, moderate and severe acne were significantly more prevalent (56.44% and 41.10% in MPG, and 35.80% and 61.11% in EPG) compared to the control group (5.61% and 4.89%). The most prevalent preconditions observed were insulin resistance syndrome in MPG (63.8%) and autoimmune thyroiditis in EPG (95.06%). Significant age-related differences in acne severity were found across all study groups (p < 0.05). In MPG, the age variable was significantly higher in the presence of mild acne, while in EPG, the age variable was significantly lower for the mild acne group. A positive association was observed between the severity of acne and insulin resistance syndrome, obesity, autoimmune thyroiditis, and hypothyroidism (p < 0.05). Risk analysis indicated a significantly higher risk (RR > 1, 95% CI RR > 1, p < 0.001) of developing moderate and severe acne in the presence of these preconditions. The presence of both metabolic and endocrine preconditions significantly increased the likelihood of developing severe acne, leading to the hypothesis that both conditions may be contributing factors to the development of acne.

Correlation Between Vitamin B12 Deficiency and Autoimmune Thyroid Diseases

BACKGROUND

Autoimmune thyroid diseases (AITD) are the most prevalent organ-specific autoimmune disorders. Vitamin B12 plays an important role in the proper functioning of the immune system. The aim of this study was therefore to investigate the correlation between vitamin B12 deficiency and AITD.

MATERIALS AND METHODS

A total of 306 patients (aged 18-65 years, mean - 37.6 ± 11.3 years and comprising 87 males and 219 females) were studied retrospectively (observational study). Patients were divided into groups: with and without vitamin B12 deficiency, and with and without AITD. Differences between groups were evaluated by Fisher's exact test for qualitative variables and by Student's t-test for quantitative variables. Correlations for quantitative factors were determined by the Pearson correlation coefficient and for qualitative factors by Spearman correlation analysis. The sensitivity and specificity of vitamin B12 deficiency for AITD were calculated by ROC analysis.

RESULTS

The vitamin B12 level was significantly lower in patients with AITD (and 200.70 + 108.84) compared to controls (393.41+150.78 p<0.0001). Patients with vitamin B12 deficiency were characterized by significantly higher mean values of anti-TPO (236.60+455.74) compared to controls (39.51+165.57 p<0.0001). Vitamin B12 levels were inversely correlated to anti-TPO levels (r=- 0.233, p<0.001). Roc analysis of vitamin B12 as a diagnostic test for AITD gave the area under curve as 0.881 (95% CI: 0.839-0.924), a sensitivity of - 0.947, a specificity of - 0.768, and a cutoff value of - 178.9.

CONCLUSION

The vitamin B12 level correlates significantly to AITD. The concentration of vitamin B12 should therefore be determined in patients with autoimmune thyroiditis as a diagnostic test with high sensitivity and good specificity.

Evaluation of Modified Melasma Area and Severity Index in Hyperthyroid Patients Receiving Anti-thyroid Drugs

BACKGROUND: Melasma is a common hyperpigmentation disorder, which causes brownish discoloration of the face. Despite unclear mechanisms, thyroid hormones were thought to play a role in melasma. AIM: This study aims to determine and compare the clinical improvement of melasma in hyperthyroid patients receiving anti-thyroid drugs. METHODS: An interventional study with a quasi-experimental design (pre-post-intervention study) was conducted at the Internal Medicine Outpatient Clinic and Dermatology and Venereology Outpatient Clinic, Cipto Mangunkusumo Hospital, Jakarta, Indonesia, from July 2019 to March 2020. A comparative analysis was done to compare the modified melasma area and severity index (mMASI) in hyperthyroid patients before and after 12 weeks of anti-thyroid drugs. All subjects did not receive any additional topical therapies for their melasma. The clinical features were evaluated objectively at baseline and 12th-week visit, by mMASI score on different areas of the face (forehead, left-right malar, and chin) and Wood’s lamp examination. RESULTS: All areas showed a decline in mMASI score components (e.g., involvement areas and darkness degree) after 12 weeks of treatment. However, only the malar area showed a significant decline (p < 0.05). Wood’s lamp examination at baseline revealed dermal type melasma on 17 subjects, mixed type on six subjects, and epidermal type on one subject. All types remained unchanged after 12 weeks of treatment. CONCLUSIONS: Our study demonstrated that mMASI score in malar area improved significantly, this might be because malar area included this study were comprised of epidermal, dermal, and mixed type. On the other hand, based on Wood’s lamp examination, all types of melasma remained unchanged after 12 weeks of treatment.

Examination of skin lesions in rats with induced hyperthyroidism and hypothyroidism

We investigated the pathogenesis of skin lesions due to hypothyroidism and hyperthyroidism in rats. We used 30 rats allocated into hypothyroidism, hyperthyroidism and control groups. Blood samples were evaluated for levels of thyroid stimulating hormone (TSH), tri-iodothyronine (T3) and thyroxine (T4). Skin samples were examined for melan-A, lymphatic vessel endothelial hyaluronic acid receptor 1 (LYVE1), cluster of differentiation 31 (CD31), protein gene product 9.5 (PGP9.5), calretinin, chromogranin, synaptophysin and pancytokeratin. Histopathological examination of the skin sections revealed thickened epidermis in the hyperthyroidism group due to an increased number of cells, and a decreased number of hair follicles and epithelial cell rows in the epidermis with an increased number of fat cells in the dermis of the rats in the hypothyroidism group. No significant difference was observed in the immunoreactions of pancytokeratin, PGP9.5, CD31 and synaptophysin among the groups. The hyperthyroidism and hypothyroidism groups exhibited a marked increase in melan-A immunoreaction. Expression of LYVE-1, chromogranin and calretinin was increased in the hyperthyroidism group and decreased in the hypothyroidism group. We found that melan-A, LYVE-1, chromogenin and calretinin play an important role in the pathogenesis of skin lesions caused by thyroid disorders.

Melasma and thyroid disorders: a systematic review and meta-analysis

BACKGROUND

Thyroid hormones may play a key role in melasma; however, melasma link with thyroid disorders remains controversial.

OBJECTIVES

To compare the serum levels of thyroid-stimulating hormone (TSH), T4, T3, anti-thyroid peroxidase (anti-TPO), and antithyroglobulin between patients with melasma and control group using meta-analysis.

METHODS

We screened 10 databanks and search engines, searched mesh and nonmesh terms. The identified evidences were reviewed and quality assessed using the Newcastle-Ottawa Scale (NOS). The heterogeneity between the primary results was investigated using Cochrane and I-square indices. Random effect model was applied to combine the standardized mean differences of thyroid function indicators between patients with and without melasma. P values meta-analysis was used to investigate the association between anti-TPO and melasma.

RESULTS

We included seven studies, 473 cases, and 379 controls that had been investigated. The total standardized mean differences (95% confidence intervals) of TSH, T3, T4, and antithyroglobulin antibody between cases and controls were estimated to be 0.33 (0.18, 0.47), -0.01 (-0.20, 0.19), -1.50 (-2.96, -0.04), and 0.62 (0.14, 1.11), respectively. The corresponding figures among women were 0.35 (0.17, 0.52), 0.10 (-0.17, 0.38), -2.75 (-6.30, 0.81), and 0.99 (0.14, 1.83), respectively. P value of meta-analysis showed a significant relationship between anti-TPO serum level and melasma (Fisher = 26.80, P = 0.020).

CONCLUSION

Serum levels of TSH, anti-TPO, and antithyroglobulin antibody were significantly higher in patients with melasma than those without melasma. Moreover, these differences were more severe among women with melasma.

Is There Any Association Between Psoriasis and Hashimoto's Thyroiditis?

Background

The association between psoriasis and Hashimoto’s thyroiditis has been evaluated in many retrospectives and prospective studies with varying numbers of patients and study designs. A positive association had been found certain studies, while no clear association in others.

Objective

The objective of this study was to evaluate the prevalence of Hashimoto’s thyroiditis in patients with psoriasis in comparison with healthy matched control from the same geographical region.

Methods

A case-control study was conducted from October 2017 to October 2018 in Faiha Specialized Diabetes, Endocrine, and Metabolism Center (FDEMC). Fifty-six psoriatic patients were compared with 54 healthy, gender, age and body mass index-matched controls. All participants had thyroid evaluation in the form of measurement of thyroid-stimulating hormone (TSH), free thyroxine (FT4), antithyroid peroxidase antibody (TPO Ab), and antithyroglobulin antibody (Tg Ab). Thyroid ultrasound examination was performed looking for volume, hypo-echogenicity, pseudo-nodularity, and increased vascularity. Assessment of psoriasis severity was conducted using the Psoriasis Area and Severity Index (PASI) score.

Results

Significantly higher prevalence of TPO Ab, Tg Ab, hypo-echogenicity, pseudo-nodularity, and increased vascularity was found in patients with psoriasis. The prevalence in psoriasis versus control was for TPO Ab (25.0% vs 9.3%, p = 0.02), Tg Ab (30.4% vs 11.1%, p = 0.01), hypo-echogenicity (30.4% vs 9.3%, p = 0.02), pseudo-nodularity (16.1% vs 0%, p = 0.002), and increased vascularity (35.7% vs 5.6%, p = 0.001). Patients with psoriasis with age of onset at diagnosis ≥40 years old and obesity were significantly more likely to have positive TPO Ab with a prevalence of (42.1% and 40.7%, respectively). There were no significant differences in the prevalence of hypothyroidism and subclinical hypothyroidism between psoriasis and control. In patients with psoriasis, psoriasis types, severity, duration, age, gender, smoking status, type 2 diabetes, and personal and family history of autoimmune diseases did not correlate with thyroid autoimmunity.

Conclusions

This study demonstrates a clear association between psoriasis and Hashimoto’s thyroiditis in the form of a significantly higher prevalence of TPO Ab, Tg Ab, hypo-echogenicity, pseudo-nodularity, and increased vascularity. Hence, thyroid evaluation by anti-thyroid antibodies, particularly TPO Ab, and ultrasound should be included in the care of psoriasis patients.

A Detailed Protocol for Perspiration Monitoring Using a Novel, Small, Wireless Device

Perspiration monitoring can be utilized for the detection of certain diseases, such as thermoregulation and mental disorders, particularly when the patients are unaware of such disorders or are having difficulty expressing their symptoms. Until now, several devices for perspiration monitoring have been developed; however, such devices tend to have a relatively large exterior, considerable power consumption, and/or less sensitivity. Recently, we developed a small, wireless device for perspiration monitoring. The device consists of a temperature/relative humidity (T/RH) sensor, battery-driven small data logger, and silica gel as a desiccant in a small cylindrical exterior. The T/RH sensor is placed between the detection windows (through which the water vapor from the skin enters) and the silica gel. The underlying principle of the perspiration monitoring device is based on Fick's law of diffusion, which means that water vapor flux from the skin to the silica gel (i.e. transepidermal water loss and perspiration) can be captured by change in humidity at the T/RH sensor. In addition, a baseline subtraction method was adopted to distinguish perspiration and transepidermal water loss. As shown in the previous report, the developed device can monitor the perspiration at any sites of the body in an easy, wireless manner. However, detailed methods of how to use the device have not been disclosed yet. In this article, therefore, we would like to show the point-by-point tutorials of how to use the device for perspiration monitoring, by showing the sympathetic activity test with the sympathetic skin response monitoring as an example.

Flushing in (neuro)endocrinology

Cutaneous flushing is a common presenting complaint in endocrine disorders. The pathophysiology of flushing involves changes in cutaneous blood flow triggered by multiple intrinsic factors that are either related to physiology or disease. Flushing can be divided into episodic or persistent causes. Episodic flushing is mediated by the release of endogenous vasoactive mediators or medications, while persistent flushing results in a fixed facial erythema with telangiectasia and cyanosis due to slow-flowing deoxygenated blood in large cutaneous blood vessels. The differential diagnosis of cutaneous flushing in neuroendocrine disorders is limited, yet encompasses a broad spectrum of benign and malignant entities, including carcinoid syndrome, pheochromocytoma, Cushing syndrome, medullary thyroid cancer, and pancreatic neuroendocrine tumors. In this review, we provide a concise and up-to-date discussion on the differential diagnosis and approach of flushing in neuroendocrinology.

Development of a small wireless device for perspiration monitoring

A small and wireless device that can capture the temporal pattern of perspiration by a novel structure of water vapor collection combined with reusable desiccant has been developed. The novel device consists of a small cylindrical case with a temperature/relative humidity sensor, battery-driven data logger, and silica gel (desiccant). Water vapor of perspiration was detected by the change in relative humidity and then adsorbed by silica gel, allowing continuous recording of perspiration within a closed and wireless chamber, which has not been previously achieved. By comparative experiments using the commercially-available perspiration monitoring device, the developed device could measure perspiration as efficiently as the conventional one, with a normalized cross coefficient of 0.738 with 6 s delay and the interclass correlation coefficient [ICC(2, 1)] of 0.84. These results imply a good agreement between the conventional and developed devices, and thus suggest the applicability of the developed device for perspiration monitoring.

Association of ApaI and BsmI polymorphisms with vitiligo risk: a meta-analysis

BACKGROUND

It has been reported that polymorphisms of the vitamin D receptor gene (VDR) such as ApaI or BsmI may affect the risk of vitiligo. However, the results have been inconsistent.

AIM

To evaluate the association between two common polymorphisms (ApaI and BsmI) in the VDR gene and the susceptibility to vitiligo.

METHODS

The PubMed, Cochrane Library and China National Knowledge Infrastructure (CNKI) databases were searched, and OR with 95% CI was calculated. The strength of association and vitiligo risk was assessed under five genetic models: allele, dominant, recessive, homozygous and heterozygous.

RESULTS

Six relevant studies were identified, including five studies that assessed the ApaI polymorphism and four the BsmI polymorphism (some overlapped). The meta-analysis results indicated that either the ApaI or the BsmI gene polymorphism may increase the risk of vitiligo in East Asian populations (aa + Aa vs. AA: OR = 1.40, 95% CI 1.01-1.96, P < 0.05; bb vs. Bb + BB: OR = 1.32, 95% CI 1.09-1.59, P < 0.01). No publication bias was detected in this meta-analysis.

CONCLUSION

The current meta-analysis suggests that the ApaI a allele or BsmI bb genotype are associated with the risk of vitiligo in East Asian populations. Thus, these polymorphisms could be potential biomarkers for early detection of vitiligo.

The association of vitamin D receptor gene polymorphisms and serum 25-hydroxyvitamin D levels with generalized vitiligo

BACKGROUND

Vitiligo is an acquired depigmentation autoimmune disorder that has been described as being associated with lower levels of 25-hydroxyvitamin D [25(OH)D]. Genetic variations within the vitamin D receptor (VDR) gene could lead to significant receptor dysfunction, and could further affect the formation of the biologically active 25(OH)D. Therefore, we hypothesized that VDR polymorphisms might be involved in vitiligo by affecting the formation of 25(OH)D.

OBJECTIVES

To evaluate the potential association between VDR polymorphisms and vitiligo susceptibility and the serum levels of 25(OH)D.

METHODS

We performed a hospital-based study of 749 patients with vitiligo and 763 matched controls. We investigated four VDR polymorphisms (FokI, BsmI, ApaI and TaqI) to determine whether they are associated with vitiligo susceptibility in the Chinese population. In addition, the levels of 25(OH)D were measured to evaluate possible associations between the VDR polymorphic variants and clinical and laboratory findings of vitiligo.

RESULTS

A significantly decreased risk of developing vitiligo was found to be associated with the BsmI-B, ApaI-A and TaqI-t alleles. According to the genotype distribution, 25(OH)D concentrations were significantly higher in patients carrying the FokI ff or ApaI AA genotypes compared with those carrying the FF or aa genotypes. Logistic regression analysis also showed a dose-response relationship between decreased risk of vitiligo and increased 25(OH)D levels in ApaI-A variant genotype carriers.

CONCLUSIONS

Our findings suggest that these VDR polymorphisms are associated with 25(OH)D levels and that there exists a genetic predisposition for vitiligo in the Chinese population.

The evaluation of thyroid diseases in patients with pemphigus vulgaris

Background. Thyroid disorders may affect all of the organ systems of the body and they are also highly associated with a wide variety of skin disorders. The aim of this study was to investigate the prevalence of thyroid function abnormalities and thyroid autoimmunity in patients with pemphigus vulgaris (PV) and to determine the association between thyroid disorders and clinical involvement and systemic corticosteroid treatment in patients with PV. Methods. The study consisted of eighty patients with PV and eighty healthy individuals. Thyroid functions (fT3, fT4, and TSH) and thyroid autoimmunity (anti-thyroid peroxidase (anti-TPO), and anti-thyroglobulin (anti-Tg) antibodies) were investigated in both groups. Primary thyroid disease (PTD) was diagnosed with one or more of the following diagnostic criteria: (i) positive antithyroid antibodies, (ii) primary thyroid function abnormalities. Results. Significant changes in the serum thyroid profile were found in 16% (13/80) of the PV group and 5% (4/80) of the control group. Positive titers of antithyroid antibodies (anti-TPO and anti-Tg) were observed in 7 patients (9%) with PV and one in the control group (1,2%). Hashimoto thyroiditis was diagnosed in 9% of PV patients and it was found to be more prevalent in the mucosal form of PV. PTD was found in 13 of (%16) PV patients which was significantly high compared to controls. PTD was not found to be associated with systemic corticosteroid use. Free T3 levels were significantly lower in PV group compared to the control group and free T4 levels were significantly higher in PV group compared to the controls. Conclusions. PV may exist together with autoimmune thyroid diseases especially Hashimoto thyroiditis and primer thyroid diseases. Laboratory work-up for thyroid function tests and thyroid autoantibodies should be performed to determine underlying thyroid diseases in patients with PV.

Thyroid Hormone Analogue Stimulates Keratinocyte Proliferation but Inhibits Cell Differentiation in Epidermis

Gross clinical manifestations of thyroid hormone (TH) imbalance are often first seen in the skin where TH plays an integral role in sustaining natural function. Although mounting evidence suggests that TH plays an important role in epidermal proliferation and wound healing, the physiologic role of thyroid hormone in skin is not well understood. In the current study, we investigated the effect of a natural thyroid hormone analogue-3, 3', 5-triiodo-thyroacetic acid (TRIAC) on regulating proliferation and differentiation and its possible molecular mechanism in normal human epidermal keratinocytes and C57BL/6 mice. We determined that TRIAC could stimulate epidermal thickening in mice and promote human keratinocyte proliferation by activating Cyclin D1 expression and promoting entrance into S phase. Moreover, TRIAC might inhibit cell differentiation through repressing the expression of Casein Kinase 1 (CK1), which is a key regulatory protein involved in the control of cell differentiation. Taken together, our data explored the physiologic effect of TRIAC on skin and the possible molecular mechanism of TRIAC, which might be an interesting compound for the treatment of hyperkeratotic skin disorders.

Association between Vitiligo and Thyroid Autoimmunity

Background. Vitiligo is a common skin disorder characterized by macular depigmentation of the skin. The etiopathogenesis of the disease is still unclear, but there is evidence that autoimmunity and endocrine disfunction may be involved. Objective. The aim of this study was to determine whether vitiligo is statistically associated with thyroid autoimmunity. Method. In a prospective case-control study, we compared the frequency of thyroid autoantibodies (thyroglobulin antibody, anti-Tg and thyroid peroxidase antibody, and anti-TPO) in 33 patients with vitiligo and in 33 healthy volunteers. Thyroid autoantibodies and thyroid hormones (thyroxine (T4), triiodothyronine (T3), and thyroid stimulating hormone (TSH) were measured in all subjects. Results. Thyroid functional abnormalities were found in 6 (18.18%) patients. Anti-Tg and anti-TPO were positive in 9 (27.27%) and 8 (24.24%) patients, respectively. In control group, only one subject (3.03%) had abnormalities in thyroid hormonal status, and two subjects had positive thyroid autoantibodies. Compared with the control group, the frequency of both anti-Tg and anti-TPO was significantly higher in those with vitiligo (P < .05). Conclusion. This study shows a significant association between vitiligo and thyroid autoimmunity, and that tests to detect thyroid autoantibodies are relevant in patients with vitiligo.

Urticaria and thyroid autoimmunity

BACKGROUND

Chronic urticaria is a common clinical condition whose etiology, in about 75% of cases, is unknown and is therefore called chronic idiopathic urticaria (CIU). A link between CIU and autoimmune thyroid diseases was proposed several decades ago. Here we review this topic.

SUMMARY

Several studies have been performed to determine if and to what degree there is an association between CIU and autoimmune thyroid diseases, particularly autoimmune thyroiditis. Many of these studies were not well controlled, however. Approximately one-fourth of CIU patients have serological evidence of thyroid autoimmunity, suggesting that these two disorders are associated. The mechanisms for the apparent association between CIU and serological evidence of thyroid autoimmunity are not clear. There are no data regarding the correlations between CIU and histological features of autoimmune thyroiditis or hypothyroidism. Despite this, there are anecdotal reports regarding L-thyroxine administration in patients with CIU.

CONCLUSIONS

Screening for thyroid autoimmunity is probably useful in patients with CIU. More solid evidence, based on still lacking well-conducted controlled studies, is desirable to determine if there is a therapeutic role for L-thyroxine treatment in ameliorating the skin manifestations of urticaria.

Acquired ichthyosis in a child with autoimmune thyroiditis

Acquired ichthyosis is a rare cutaneous disorder characterized by dry, rough skin with prominent scaling, that involves symmetrically the trunk and limbs and especially on the extensor surfaces. It appears most commonly in adults in association with malignant, autoimmune, metabolic, endocrine, and infectious diseases. We describe a child with acquired ichthyosis in whom an autoimmune hypothyroidism was detected; furthermore, replacement therapy with L-thyroxine resulted in complete remission of ichthyosis.

A pilot study assessing the role of 25 hydroxy vitamin D levels in patients with vitiligo vulgaris

BACKGROUND

Very low vitamin D levels have been noted in patients with a variety of autoimmune diseases.

OBJECTIVE

To determine whether low vitamin D levels are associated with autoimmunity in the setting of vitiligo vulgaris.

METHODS

A prospective cohort study was conducted on 45 consecutive patients with vitiligo vulgaris. 25-Hydroxyvitamin D levels were determined from sera collected at the time of study enrollment. Logistic regression analysis of the relationship of 25-hydroxyvitamin D levels to disease state was performed, including surface area, recent-onset vitiligo, Fitzpatrick skin type and ethnicity, dairy intake, and both personal and family history of autoimmunity. Multiple univariate and multivariate logistic regression models were developed to assess the interrelationship of these parameters.

RESULTS

25-Hydroxyvitamin D levels were divided into 3 groups: 31.1% were normal (>30 ng/mL), 55.6% were insufficient (<30 ng/mL), and 13.3% were very low (<15 ng/mL). Insufficient 25-hydroxyvitamin D levels were associated with increasing Fitzpatrick phototypes (odds ratio [OR] = 1.76, 95% confidence interval [CI] = 1.12-2.77). Very low 25-hydroxyvitamin D levels were associated with comorbid autoimmune illness (OR = 10.00, 95% CI = 1.06-94.7), but not with age, gender, race/ethnicity, family history of vitiligo or autoimmune disease, new-onset disease, or body surface area affected. None of the surveyed patients reported daily vitamin D intake of greater than 200 IU.

LIMITATIONS

This study consists of a small cohort that assesses point prevalence without assessing seasonal variation in vitamin D levels.

CONCLUSIONS

Very low 25-hydroxyvitamin D levels (<15 ng/mL) appear to be a reasonable screening tool for the presence of comorbid autoimmunity. Furthermore, we demonstrate that Fitzpatrick phototype, rather than ethnicity, is specifically associated with 25-hydroxyvitamin D levels that are insufficient (<30 ng/mL).

Autoimmune thyroiditis presenting as palmoplantar keratoderma

Palmoplantar keratoderma is a heterogeneous group of hereditary and acquired disorders characterized by abnormal thickening of palms and soles. Hypothyroidism is an unusual cause of palmoplantar keratoderma, rarely reported in the literature. We report a case of a 43-year-old woman presented with a 3-month history of a diffuse palmoplantar hyperkeratosis unresponsive to topical keratolytics and corticosteroids. Her past medical and family histories were unremarkable. She complained of recent asthenia, mood changes and constipation. Laboratory evaluation revealed an autoimmune thyroiditis with hypothyroidism. Other causes of acquired palmoplantar keratoderma were excluded. After hormonal replacement therapy institution, a gradual improvement of skin condition was observed. The diagnosis of underlying causes for acquired palmoplantar keratoderma can be a difficult task; however its recognition is essential for successful treatment results. Although a very rare association, hypothyroidism must be suspected in patients with acquired palmoplantar keratoderma, particularly when it occurs in association with systemic symptoms.

Female adolescent hair disorders

Hair abnormalities can have tremendous psychosocial impacts on adolescents and young adults, and may cause a great amount of anxiety regarding physical appearance, associated illnesses, and potential clinical course. The pathophysiology of such disorders may vary,with potential congenital, infectious, autoimmune, nutritional, or environmental causes. Hair abnormalities may present as changes in hair appearance or quality, becoming weathered or fractured.An abnormal increase in hair is present in hypertrichosis and hirsutism, whereas a thinning or shedding of hair is evident in patients with telogen effluviumand alopecia areata. Diagnosis is focused on a detailed clinical history and physical exam, in addition to laboratory testing, a variety of clinical diagnostic tests, and scalp biopsy, which may be necessary to confirm some diagnoses. Many hair disorders have no cure, but clinicians can have a positive impact on their patients by identifying the abnormality and educating the patient regarding disease course. However, some conditions such as infectious hair disorders or scarring alopecia should be identified promptly to initiate treatment and ensure clinical improvement or optimal outcome.

Skin findings in thyroid diseases

BACKGROUND

In cases of thyroid diseases, many of the symptoms arise on the skin. In this study, we aimed to detect and compare the skin findings and accompanying dermatoses of patients with thyroid diseases.

MATERIALS AND METHODS

220 patients with thyroid diseases, who did not have any medical cure, and 90 healthy individuals as a control group attended our study. All of the cases were examined, and the skin findings and/or dermatoses were recorded. The skin findings in the patients and the control group were compared statistically.

RESULTS

Among 220 cases, in 125 (56.8%) skin findings were detected. The most frequently observed skin findings were chronic urticaria (6.8%), vitiligo (6.8%), diffuse alopecia (6%), acne vulgaris (5%) and acne rosacea (3.6%). No significant difference was detected statistically between the patients and control group in terms of skin findings. When compared for the presence of each dermatosis, chronic urticaria, vitiligo and pruritus were found to be significantly higher in the patient group with thyroid diseases than in the control group. In terms of the presence of skin findings, no statistical difference was detected between autoimmune hyperthyroidism and non-autoimmune hyperthyroidism, between autoimmune hypothyroidism and non-autoimmune hypothyroidism, or between autoimmune euthyroidism and non-autoimmune euthyroidism. Chronic urticaria, vitiligo, and diffuse alopecia were found to be significantly higher in patients with autoimmune thyroid diseases than in the control group. Vitiligo and diffuse alopecia were found to be higher in autoimmune hyperthyroidism patients than in the control group. Vitiligo was found to be significantly higher in autoimmune hypothyroidism patients than in the control group.

CONCLUSION

To our knowledge, no report investigating the skin findings among thyroid diseases exists in literature. We believe this study would provide data for further studies.

Cosmetic formulations containing Lithospermum erythrorhizon root extract show moisturizing effects on human skin

Retention of water in the stratum corneum of skin epidermis plays an important role in regulation of skin function. Loss of water may decline skin appearance gradually and lead to irregular skin disorders. The root extract of Lithospermum erythrorhizon (LES) is known for its various pharmacological activities. However, the potential skin care effect of LES is not clear. The aim of this study was to evaluate the moisturizing efficacy and skin barrier repairing activity of LES. For this study, 30 healthy Asian females (age 20-30) with healthy skin had applied the test emulsions twice daily over a period of 28 days. The skin properties were measured by skin bioengineering techniques. Our preliminary results indicated that LES show moisturizing effect on skin hydration in a time- and dose-dependent pattern, and the maximum increase in skin humidity was 11.77 +/- 1.18% for emulsion LES5.00. Particularly, LES-containing emulsions significantly improve skin barrier function by decreasing the value of transepidermal water loss (TEWL) in a time- and dose-dependent pattern, and the maximum decrease in TEWL value was 7.68 +/- 0.79% for emulsion LES5.00. Taken together, our data demonstrate that LES is more effective in increasing skin humidity and decreasing the TEWL values, indicating the potential skin care effects of LES.

The melanocytorrhagic hypothesis of vitiligo tested on pigmented, stressed, reconstructed epidermis

Common generalized vitiligo is an acquired depigmenting disorder characterized by a chronic and progressive loss of melanocytes from the epidermis and hair follicles. We previously proposed a new theory that vitiligo involves the chronic detachment and transepidermal loss of melanocytes caused by autoimmune, neural and impaired redox mechanisms associated with mechanical trauma. In this study, we reconstructed epidermis on dead de-epidermized dermis with normal and/or non-segmental non-lesional vitiligo (NSV) cells and tested catecholamines or sera or hydrogen peroxide. Under unstressed conditions, the number of melanocytes located in the basal layer was significantly lower in reconstructs made with melanocytes from non-lesional NSV skin and normal keratinocytes compared with controls made with autologous normal melanocytes. The number of non-lesional NSV melanocytes was even lower in reconstructs made with keratinocytes from non-lesional NSV skin. Epinephrine and H(2)O(2) could trigger the transepidermal loss of normal and vitiligo melanocytes. Some sera induced melanocyte detachment but without any clear correlation with disease activity in the donors. In conclusion, our results are the first step to obtaining a reproducible melanocytorrhagic model in vitro with some of the stressors investigated. They support the hypothesis that NSV melanocytes have an intrinsic defect, which limits their adhesion in a reconstructed epidermis, with an enhancer effect of the vitiligo keratinocyte milieu.

Autoimmune blistering disease in a patient with Graves disease and vitiligo

Autoimmune thyroid diseases have been correlated with a variety of autoimmune diseases also affecting the skin. A 56-year-old patient with a history of vitiligo is presented who was admitted for hyperthyroidism (Graves disease) and a blistering eruption. Clinical and histological appearance of the skin disorder, rapid response to corticosteroids, recurrence and remission of the lesions with discontinuation and reintroduction of corticosteroids, respectively, were all suggestive of an autoimmune blistering disease accompanying autoimmune hyperthyroidism and vitiligo.

Psoriasiform lesions and abscesses as initial manifestations of severe hypothyroidism in a previously healthy 15-year-old girl

Hypothyroidism is associated with many characteristic cutaneous manifestations; however, to the best of our knowledge, it has not previously been linked to psoriasiform lesions or multiple abscesses. We describe a previously healthy 15-year-old girl with psoriasiform lesions, abscesses, and extremely severe hypothyroidism, all presenting simultaneously. The pathophysiology of the connection is unclear, but several hypotheses are discussed. The temporal relationship of these conditions and the significant improvement of the skin lesions upon normalization of T4 levels following initiation of thyroid supplementation illustrate a direct association. It is probable that the extreme severity of hypothyroidism in our patient is implicated in the etiology of these skin lesions. This unique case illustrates that novel cutaneous manifestations may sometimes act as an early presenting sign of hypothyroidism and may be associated with more severe forms of the disorder.

Dermatologic aspects of thyroid disease

Thyroid disorders commonly have dermatologic manifestations. The purpose of the present chapter is to review and emphasize potential clinical dermatologic findings that can occur with Graves' disease, hypothyroidism and thyroid cancer. In autoimmune diseases such as Graves' disease and Hashimoto's thyroiditis the skin manifestations may be related to either thyroid hormone levels themselves or to the associated T and/or B cell abnormalities. Thyroid cancer may be associated with various syndromes that could have significant skin manifestations.

Action of topical thyroid hormone analogue, triiodothyroacetic acid in reversing glucocorticoid-induced skin atrophy in humans

The present study concerns the effect of topical treatment with a cream formulation of triiodothyroacetic acid (TRIAC) in comparison with a placebo preparation in producing a reversal of skin atrophy induced by long-term employment of topical glucocorticoid therapy in humans. A total of 39 patients with clinically verified skin atrophy due to long-term use of topical potent glucocorticoids were randomized. The changes in skin thickness, elastic fibers, and hyaluronic acid were evaluated by means of sonography and histology. After 8 weeks' treatment, the skin thickness measured by sonography increased by 16% in the epidermis, 8% in the dermis, and epidermis + dermis in the placebo group. In the TRIAC 0.1% group, the corresponding values were 24% ( p=0.063) in the epidermis, 28% ( p=0.042) in the dermis, and 25% ( p=0.039) in the epidermis + dermis. After 8 weeks, in the placebo group, the skin thickness measured by biopsy increased by 5% in the epidermis, epidermis + dermis, and 6% in the dermis. In the TRIAC 0.1% group, the corresponding values were 31% ( p=0.041) in the epidermis, 46% ( p=0.041) in the dermis and 44% ( p=0.043) in the epidermis + dermis. After 8 weeks, the elastic fibers of moderately irregular and thickened fibers increased by 56% in the placebo group and 100% ( p=0.043) in the TRIAC 0.1 group. This study indicates that topical treatment with TRIAC appears to reverse glucocorticoid-induced skin atrophy under the narrow conditions tested.

The flushing patient: Differential diagnosis, workup, and treatment

Cutaneous flushing-a common presenting complaint to dermatologists, allergists, internists, and family practitioners-results from changes in cutaneous blood flow triggered by multiple conditions. Most cases are caused by very common, benign diseases, such as rosacea or climacterum, that are readily apparent after a thorough taking of history and physical examination. However, in some cases, accurate diagnosis requires further laboratory, radiologic, or histopathologic studies to differentiate several important clinicopathologic entities. In particular, the serious diagnoses of carcinoid syndrome, pheochromocytoma, mastocytosis, and anaphylaxis need to be excluded by laboratory studies. If this work-up is unrevealing, rare causes, such as medullary carcinoma of the thyroid, pancreatic cell tumor, renal carcinoma, and others, should be considered.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the mechanisms of flushing, its clinical differential diagnosis, the approach to establish a definitive diagnosis, and management of various conditions that produce flushing.

Action of topical thyroid hormone analogues on glucocorticoid-induced skin atrophy in mice

Previously we demonstrated the stimulation of collagen synthesis in triiodothyroacetic acid (TRIAC)-topically treated human and mice. In the present study, we have evaluated the dose response effect of thyroid hormone (TH) analogues and tretinoin on glucocorticoid-induced skin atrophy in a haired mouse model. For this investigation, we treated haired mice twice daily for 7 days with various topically administered doses of TRIAC, triiodothyronine-sodium salt (T(3)-Na), diiodothyroacetic acid (DIAC), 3,5-diiodothyropropionic acid (DITPA), and tretinoin with 0.2 mM betamethasone17-valerate (BM), or with the vehicle as a control group. We also investigated a combination of commercial betamethasone dipropionate (BD) 0.05% cream and various doses of TRIAC on mouse skin. TRIAC was able to reverse the skin atrophy by 25% in a daily dose of 1 nmol/cm(2) in the presence of 0.2 mM BM (p < 0.05). Neither other TH analogues nor TRIAC in lower and higher concentrations had a significant inhibitory effect on dermal atrophy (p > 0.05). A combination of 0.2 mM BM and 10 nmol/cm(2) TRIAC was able to prevent dermal atrophy by 18%. The addition of TRIAC to 0.05% BD cream in a final concentration of 0.1% was able partially to reverse the dermal atrophy by 15% (p < 0.05). TRIAC alone in a concentration of 1,000 nmol/cm(2) stimulated dermal proliferation by 34% (p < 0.05). Other TH analogues alone had no stimulatory effect on dermal proliferation. Tretinoin 0.8 mM was able to inhibit dermal atrophy by 20% (p < 0.05) and had an effect on dermal thickness of 85% (p < 0.05). However, severe side effects with edema, erythema, and scaling were commonly observed in all tretinoin-treated mouse skin, which could partly explain the increase in dermal thickness. In contrast, no skin side effects were observed after treatment with TRIAC. This study indicates that TRIAC may have a therapeutic effect on BM-induced dermal atrophy in mouse skin and a direct stimulatory effect on dermal proliferation when given alone.

Acquired ichthyosis and hypertrichosis due to autoimmune thyroiditis: therapeutic response to thyroxine replacement

Thyroid diseases may be associated with a wide variety of dermatologic disorders. We report a 15-year-old girl with acquired ichthyosis and hypertrichosis associated with hypothyroidism resulting from autoimmune thyroiditis. Her skin lesions progressively resolved after 8 months of replacement therapy with L-thyroxine. This result supports the hypothesis that hypothyroidism in our patient can be directly related to the pathogenesis of acquired ichthyosis and hypertrichosis.

A thyroid hormone analogue, triiodothyroacetic acid, corrects corticosteroid-downregulated collagen synthesis

The aim of this study was to compare the change in collagen synthesis between topical treatments with two doses of triiodothyroacetic acid (TRIAC), a thyroid hormone analogue, and placebo, after pretreatment with topical betamethasone 17-valerate (BM). Eighteen healthy volunteers were pretreated with BM on abdominal skin for 3 days, and were then treated for 14 days with a cream containing TRIAC (0.03% or 0.1%) or a placebo cream. Collagen production was assessed by quantifying the amino terminal propeptides of human type I and type III procollagen (PINP and PIIINP) in fluids from suction-induced blisters on the treated skin. Three days of treatment with BM led to an average reduction of PINP of 70% and of PIIINP of 50%. Seven days after treatment, the median increase in PINP was 230% (p = 0.03) in the Triac 0.03% group, 148% (p = 0.2) in the TRIAC 0.1% and 5% in the placebo group. The median increase in PINP in the skin area from the start of treatment to the end of treatment was 521% (p = 0.06) in the TRIAC 0.03% group, 339% (p = 0.2) in the TRIAC 0.1% group, and 55% in the placebo group (the p values are related to baseline). Seven days after treatment, the median increase in PIIINP was 24% (p = 0.6) in the Triac 0.03% group, 23% (p = 0.6) in the TRIAC 0.1% group, and -12% in the placebo group. The median increase in PIIINP in the skin area from the start of treatment to the end of treatment was 137% (p = 0.7) in the TRIAC 0.03% group, 230% (p = 0.9) in the TRIAC 0.1% group and 58% in the placebo group (the p values are related to baseline). Histologic examinations of sections from punch biopsies taken at the end of the treatment showed more thickened collagen fibers and increased density of PINP-producing dermal fibroblasts in the TRIAC groups compared to the placebo group. The result suggests a potential role for TRIAC-containing cream concomitant with anti-inflammatory topical treatment with potent glucocorticoids to prevent their suppressive activity on dermal collagen production.

[Graves disease. An important differential diagnostic consideration for systemic lupus erythematosus]

Graves disease is a frequent cause (30-40%) of hyperthyroidism. In addition to the classic clinical triad (goiter, exophthalmos and tachycardia), symptoms relating to other organ systems may be found at presentation. Cutaneous manifestations play an important role and may initially be the only clue to the endocrine disorder. A 40-year-old woman with Graves disease presented with features of systemic lupus erythematosus. She had a malar rash, as well as marked hematological changes (thrombocytopenia and leukocytopenia) and antinuclear antibodies (1:640). She also had hyperthyroidism and Graves disease-specific thyroid autoantibodies (TSIg). Her symptoms improved after initiation of antithyroid therapy. Because of overlapping clinical and laboratory criteria, Graves disease can mimic systemic lupus erythematosus. The differentiation requires careful laboratory evaluation. Moreover, both autoimmune diseases may occur in the same patient.

Safety and efficacy of 4% hydroquinone combined with 10% glycolic acid, antioxidants, and sunscreen in the treatment of melasma

BACKGROUND

Melasma, also known as mask of pregnancy, is a common, acquired hypermelanosis seen in women with Fitzpatrick skin types II-V, and is often recalcitrant to treatment with depigmentation agents. Glycolic acid has been added to hydroquinone formulations in the past to enhance their depigmentation effects, but may cause irritation, leading to postinflammatory hyperpigmentation.

AIM

To assess the safety and efficacy of a cream containing 4% hydroquinone, 10% buffered glycolic acid, vitamins C and E, and sunscreen (Glyquin, ICN Pharmaceuticals, Costa Mesa, USA) vs. a cream containing sunscreen alone in the depigmentation of epidermal melasma of the face.

METHODS

Thirty-nine Hispanic women, Fitzpatrick skin types III-V, with bilateral epidermal melasma were enrolled in a randomized controlled trial lasting 12 weeks. Patients underwent twice-daily full-face application with the study cream or with the cream containing sunscreen only. Changes in pigmentation were measured using a mexameter, the melasma area and severity index (MASI), and a global evaluation by the patient and blind investigator. Safety evaluations were performed at each follow-up visit.

RESULTS

Thirty-five patients completed the trial. Irritation was more common with the study cream, but resolved with temporary cessation of cream application and the addition of moisturizers. Mexameter results demonstrated a significant decrease in the degree of pigmentation using the study cream compared with the cream containing sunscreen alone (P < 0.0001). Fifteen of 20 patients (75%) using the study cream improved, whereas only two of 15 patients (13%) improved using sunscreen alone.

CONCLUSIONS

A cream containing 4% hydroquinone, 10% buffered glycolic acid, vitamins C and E, and sunscreen is safe and effective in the treatment of melasma.

Cutaneous manifestations of endocrine disorders: a guide for dermatologists

Dermatologists may commonly see skin lesions that reflect an underlying endocrine disorder. Identifying the endocrinopathy is very important, so that patients can receive corrective rather than symptomatic treatment. Skin diseases with underlying endocrine pathology include: thyrotoxicosis; hypothyroidism; Cushing syndrome; Addison disease; acromegaly; hyperandrogenism; hypopituitarism; primary hyperparathyroidism; hypoparathyroidism; pseudohypoparathyroidism and manifestations of diabetes mellitus. Thyrotoxicosis may lead to multiple cutaneous manifestations, including hair loss, pretibial myxedema, onycholysis and acropachy. In patients with hypothyroidism, there is hair loss, the skin is cold and pale, with myxedematous changes, mainly in the hands and in the periorbital region. The striking features of Cushing syndrome are centripetal obesity, moon facies, buffalo hump, supraclavicular fat pads, and abdominal striae. In Addison disease, the skin is hyperpigmented, mostly on the face, neck and back of the hands. Virtually all patients with acromegaly have acral and soft tissue overgrowth, with characteristic findings, like macrognathia and enlarged hands and feet. The skin is thickened, and facial features are coarser. Conditions leading to hyperandrogenism in females present as acne, hirsutism and signs of virilization (temporal balding, clitoromegaly).A prominent feature of hypopituitarism is a pallor of the skin with a yellowish tinge. The skin is also thinner, resulting in fine wrinkling around the eyes and mouth, making the patient look older. Primary hyperparathyroidism is rarely associated with pruritus and chronic urticaria. In hypoparathyroidism, the skin is dry, scaly and puffy. Nails become brittle and hair is coarse and sparse. Pseudohypoparathyroidism may have a special somatic phenotype known as Albright osteodystrophy. This consists of short stature, short neck, brachydactyly and subcutaneous calcifications. Some of the cutaneous manifestations of diabetes mellitus include necrobiosis lipoidica diabeticorum, diabetic dermopathy, scleredema adultorum and acanthosis nigricans.

Autoimmune thyroid diseases: etiology, pathogenesis, and dermatologic manifestations

Autoimmune thyroid disease (AITD) including Graves' disease, Hashimoto's thyroiditis, and idiopathic hypothyroidism (atrophic Hashimoto's thyroiditis) is of vital concern to the dermatologist. This article reviews the cutaneous manifestations of Graves' disease and Hashimoto's thyroiditis. Recognition of dermatologic manifestations of AITD may alert practitioners to investigate for these disorders. The immune response involved in the pathogenesis of AITD is detailed. Current understanding of the role of genetic and environmental factors, antigens, and apoptosis are elaborated. The future holds exciting insight into the etiology, pathogenesis, and treatment of AITD.