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Palmoplantar keratoderma in myxedema
R R Mittal
#97, New Lal Bagh, Patiala - 147 001, Punjab
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Mittal R R, Jha A. Palmoplantar keratoderma in myxedema. Indian J Dermatol Venereol Leprol 2002;68:242
AbstractA 45-years-old woman came with diffuse yellowwaxy thickening, dryness and scaly skin of palms and soles and thickening of knuckles on dorsa of hands since 2 years. In addition, she had hoarseness of voice, weight gain, slow response, intolerance to cold, loss of pubic and axillary hair, generalised dryness and coarseness of skin, and mask like fades. Diagnosis of palmoplantar keratoderma and myxedema was confirmed by investigations.
Palmoplantar keratoderma (PPK) is a multjetiological disorder which is subclassified into two main types that is hereditary- congenital and acquired. Acquired PPK may be associated with neurodermatitis, psoriasis, lichen planus, tineasis, Reiter′s syndrome, pityriasis rubra pilarjs, verrucae, fungal infections, keratoderma climactericum, contact dermatitis and syphilis. PPK in association with myxedema was first reported 1952. Myxedema associated with severe palmar keratodema was reported later in 1977 followed by another case report in 1986. Increased propensity to overkeratinisation could be responsible for PPK. Striking improvement in long standing PPK with thyroid hormones, further supported that causal relationship was possible between PPK and myxedema.
A 45-year-old woman came with the complaint of non pruritic diffuse thickening of plams and soles for the past 2 years. The patient gave history of weight gain, hoarseness of voice, stiffness of joints, difficulty in extension of hand, intolerance to cold and was in menopause for past 1 year. The patient was alert though her responses were slow. There was generalized coarseness, dryness of skin and loss of pubic and axillary hair. The palms and soles showed diffuse yellow, waxy, hyperkeratotic skin. The dorsa of the hands also showed thickening which was more prominent on the knuckles.
The endocrine function tests showed: serum T3-0.92ng/ml (normal: 0.8-1.8), T46.7mcg/dl (normal: 5-11.5) and TSH-4.2 µu/ml (normal: 0.25-3.8), thus confirming the diagnosis of myxedema. Cholesterol level was 180 mg%. Skin biopsy was taken from the sole and showed the following: marked hyperkeratosis, hypergranulosis and acanthosis.
The patient was put on thyroid hormone (eltroxin 150mgOD) and topical, keratolytics and steroids, Steady improvement occurred in the form of disappearance of stiffness of fingers, decrease in thickness, dryness of skin and disappearance of scales, during 8 months therapy and followup.
The present case could be of PPK due to associated myxedema or a case of PPK climactericum. PPK climactericum was excluded as involvement was diffuse and histopathology showed no feature of spongiosis with exocytosis. She had taken treatment from other sources but improvement this time was far better after topical therapy along with thyroid hormone. This also favoured the fact that PPK was due to myxedema. We do agree with the opinion of Hodak et al that although rare, myxedema could be a cause of PPK due to its propensity for overkeratinisation and addition of thyroid hormone therapy helps in treating PPK.
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