Cutaneous manifestations of thyroid disease

Pretibial myxedema in Grave's disease: A case report and treatment review of the literature

Key Clinical Message

Pretibial myxedema is a rare skin lesion in Grave's disease, which required topical glucocorticoid administration in long-term treatment. The patient's lesion has shrunk and become flatter than before treatment.

Abstract

We present a case of biopsy-verified pretibial myxedema in a 70-year-old male patient with diagnosed hyperthyroidism and no prior history of Graves' disease. Topical corticosteroid and antithyroid drug administration led to successful resolution of the skin lesions. This case emphasizes the importance of considering pretibial myxedema even in atypical presentations of Graves' disease and underscores the value of prompt treatment.

Dermatologic manifestations of thyroid disease: a literature review

Introduction

Thyroid hormone is considered one of the key regulatory hormones for skin homeostasis. Multiple organs are affected by the release of peripheral thyroid hormones (T4 and T3) further regulating various functions at a cellular level. Specifically, skin is considered an important target organ in which the thyroid hormone has a significant impact. Multiple skin diseases are associated with thyroid hormone dysregulation. However, other striking dermatologic manifestations are seen in nails and hair as well. Hypothyroidism, hyperthyroidism, and thyroid cancer can have an array of cutaneous manifestations, and we present the recent updates in this field.

Methods

A PubMed search was performed for updates in any new skin disease findings and treatments between 2010 and 2022. Research published in the past decade and previously known foundational skin findings associated with thyroid disease were presented in this review.

Conclusion

Cutaneous manifestations of thyroid disease is one of the first notable signs of thyroid hormone dysregulation. This article reviews the recent updates on the thyroid and skin interplay, and it further discusses overt visible findings and various available treatment modalities.

Graves' disease complicated by concurrent thyroid eye disease and pretibial myxedema successfully treated with teprotumumab

We report a 51‐year‐old woman with thyroid eye disease and biopsy‐proven pretibial myxedema that was subsequently treated with teprotumumab with improvement.

Physical Examination for Endocrine Diseases: Does It Still Play a Role?

A physical examination represents a fundamental step in diagnosing diseases. Due to the role that hormones play in the regulation of numerous biological processes in various organs and systems, endocrine diseases cause a variety of clinical manifestations that can be easily identified with a careful physical examination and can guide the clinician to specific diagnoses. Furthermore, the presence of specific clinical signs in various endocrine-metabolic diseases can predict the risk of developing comorbidities and serious adverse events. In this article, we present some of the main clinical signs of endocrine-metabolic diseases and the risk of comorbidities, summarizing the pathogenetic mechanisms that lead to their formation. The aim is to highlight how the identification of these specific signs can reduce the number of dynamic tests and the costs necessary to reach the diagnosis and allow the early identification of any complications associated with these diseases, improving the clinical management of affected patients.

Pretibial myxedema in a euthyroid patient: a case report

Background

Pretibial myxedema also known as localized myxedema, thyroid dermopathy, or infiltrative dermopathy and rarely as localized mucinosis is an infrequent manifestation of Graves’ disease. It can appear before, during, or after the thyrotoxic state. Euthyroid pretibial myxedema is a rare presentation with few case reports in the literature. This case highlights the importance of considering pretibial myxedema when characteristic skin lesions are observed in a euthyroid patient.

Case presentation

A 72-year old male Ethiopian patient with a very rare presentation of biopsy-proven pretibial myxedema in a euthyroid state without history of thyroid disease and absence of thyroid autoimmune markers. Resolution of skin lesion was achieved after topical corticosteroid application.

Conclusion

Absence of history of thyroid disorder and normal thyroid function tests should not exclude the diagnosis of pretibial myxedema.

Obesity-associated lymphedematous mucinosis and stasis mucinosis

Cutaneous dermal mucinoses are a group of conditions characterized by abnormal deposition of mucin (hyaluronic acid and sulfated glycosaminoglycans) in the dermis. They can be classified either as localized or generalized forms and occur primarily or secondarily to systemic disorders. Obesity-associated lymphedematous mucinosis and pretibial stasis mucinosis are uncommon and relatively newly recognized disorders occurring in obese patients or in patients with venous insufficiency. Clinically, patients present with papules and nodules progressing to plaques and arising in an erythematous and edematous basis on the legs, especially the shins. Histopathologic examination indicates mucin deposition in the superficial portion of the dermis, angioplasia with an increase in small blood and/or lymphatic vessels, vertically running vessels, slight fibrosis, and no inflammation. Laboratory workup and histopathologic testing are helpful in differentiating these entities from pretibial myxedema (thyroid dermopathy), which represents the main differential diagnosis. Obesity-associated lymphedematous mucinosis and stasis mucinosis are not different entities but belong to a spectrum of mucinoses secondary to an increased body mass index, chronic lymphedema, and/or chronic venous insufficiency.

The relationship between the severity of coronary artery disease and skin measurement parameters

PURPOSE

This study aimed to investigate the relationship between skin parameters and CAD.

MATERIALS AND METHODS

The study included 50 patients diagnosed with coronary artery disease as the patient group and 45 volunteers without any known coronary artery disease as the control group. The participants' skin TEWL, pH, temperature, electrical capacitance, sebum, and elasticity values were measured using noninvasive methods at the forehead, back, and forearm.

FINDINGS

Skin temperature was significantly higher in the back and forehead regions in the patient group. No difference was found between the sebum values of the patient and control groups at the back and forehead. A significantly higher result was obtained for the forearm area. The pH was significantly lower in the patients' forearm, although the obtained values were within the normal range. The TEWL was significantly higher in patients in all three regions. In terms of flexibility, R2 was significantly higher in the back and forehead regions of the patient group, and the R6 was significantly higher in the patient group in all three regions. In addition, there was no correlation between skin parameter and SYNTAX score increase measurements.

CONCLUSION

It can be suggested that skin sebum and TEWL measurements can be accepted as cheap and noninvasive methods of predicting CAD.

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.

Skin signs of systemic diseases

The skin should not be considered as an isolated organ but rather as a definite functioning system that communicates with the internal environment. Skin signs of systemic diseases occur frequently and sometimes feature the first symptoms of an internal disease; furthermore, these manifestations may be the sole expressions of otherwise asymptomatic systemic disorders. A number of dermatologic signs, symptoms, and disorders can be invaluable as markers of systemic disease. Although a plethora of specialized modern diagnostic tests are available, the skin still remains the only organ of the body that is immediately and completely accessible to direct clinical examination. This contribution reviews the skin signs of systemic diseases. The description of the clinical features of skin lesions observed in several internal diseases will be useful to general physicians, internists, and dermatologists in the diagnosis of a systemic disease.

Cutaneous manifestations of thyroid disease: a case of thyroid-induced myxedema

The cutaneous manifestations of thyroid disease can be present in the hair, nails, and local or diffuse locations throughout the skin. Traditionally, thyroid-associated mucin deposition is present in a pretibial location on bilateral lower legs. We present a case of a growing plaque on the lower back of a 10-year-old girl, whose appearance coincided with a recent diagnosis of Hashimoto's thyroiditis.

[Skin signs of systemic diseases]

Many aspects of cutaneous signs are of importance to nondermatologists, as skin manifestations can reflect internal disease states, either directly or as a result of a complication or treatment and therefore can lead to the diagnosis of systemic illness. Serious morbidity and mortality can be avoided by early recognition of only minor cutaneous manifestations signaling internal problems. Limited forms of collagen vascular disease exemplify the important marker function of the skin for diagnosis as well as for prognosis with their typically favorable course permitting a less aggressive treatment. The utmost important prerequisite of diagnosing skin conditions is an accurate and thorough examination of the skin, the adjacent mucous membranes and the integumentary appendages. In a first step, the primary site of the cutaneous condition should be identified (e.g. epidermal, dermal or subdermal) and then the form, the pattern, and distribution should be recognized. There are many comprehensive and excellent textbooks available for guidance. This article focuses on the more common dermatologic conditions linked to different organ systems involved (excluding infectious diseases, metabolic diseases and drug induced conditions).