Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Letter To Editor
2004:70:6;380-382
PMID: 17642674

Pretibial myxedema, ophthalmopathy and acropachy in a male patient with Graves disease

S Veeranna, Kushalappa, Jayadev Betkerur, Savitha
 Department of Skin and STD, J.S.S. Medical College Hospital, Mysore, India

Correspondence Address:
S Veeranna
Department of Skin and STD, J.S.S.Hospital, Mysore, Karnataka - 570004
India
How to cite this article:
Veeranna S, K, Betkerur J, S. Pretibial myxedema, ophthalmopathy and acropachy in a male patient with Graves disease. Indian J Dermatol Venereol Leprol 2004;70:380-382
Copyright: (C)2004 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

The thyroid gland plays an important role in the maintenance of normal cutaneous function. Five per cent of men and 15% of women with thyroid dysfunction show cutaneous changes.[1] Graves′ disease is the most common cause of hyperthyroidism, affecting 15-50 of 100000 people per year, mostly females.[2] Classical findings include thyroid swelling, exophthalmos, pretibial myxedema and acropachy.[2] We report a man presenting with all the features.

A 29-year-old man presented with a history of asymptomatic swelling over the legs for the past 2 years. It was gradual in onset and progressive in nature. There was no history of trauma, excessive sweating, heat intolerance or loss of appetite. The patient had undergone thyroidectomy 2½ years back for Graves′ disease. Skin examination revealed multiple well-defined plaques and nodules of varying size situated bilaterally over the tibia. The overlying skin was waxy and indurated with some areas of hyperpigmentation [Figure - 1]. There was clubbing of the nails with thickened periungual skin [Figure - 2]. The patient also had exophthalmos.

Routine blood and urine examinations were normal. Thyroid function tests showed decreased T3 (0.30 ng/ml) and T4 (2.10 mg/ml) and increased TSH (39.41 mIU/ml) levels, suggestive of hypothyroidism. A skin biopsy specimen from the pretibial skin showed normal epidermis, marked dermal pallor due to mucin deposition and dispersed stellate shaped fibroblasts, findings suggestive of myxedema.

The patient was put on oral thyroxin and received 5 doses of intralesional triamcinolone, 0.5-1 ml per lesion, with marked improvement in the skin lesions. Later, a high potency steroid ointment was used.

Graves′ disease is an autoimmune disease of the thyroid gland with IgG antibodies against TSH-R.[2] The triad of ophthalmopathy, dermopathy and acropachy tends to occur chronologically in the course of the disease.[2] Graves′ ophthalmopathy is found in 30-45% of patients. It can manifest as lid lag, exophthalmos, strabismus, lagophthalmos or optic neuropathy.[2]

Pretibial myxedema is also known as thyroid dermopathy.[3] Clinically it may present as non-pitting edema, nodules and tuberous lesions, or the elephantiasic type.[4] The overlying skin is waxy and translucent with a ′peau d′orange′ appearance. There may be overlying hypertrichosis or hyperhidrosis. Common sites of affection are the pretibial area, arms, shoulders, and neck.[4] It may not be related to levels of thyroxin.[3] Correction of thyrotoxicosis has no effect on skin lesions.[5] It occurs in 4% of patients of hypothyroidism.[2] It can also be seen in Hashimoto′s thyroiditis and in euthyroid states.[3] Dermopathy in Graves′ disease may occur many years after ophthalmopathy.[2]

The exact pathogenesis of dermopathy is not known. However, the orbital and pretibial fibroblasts are probably the targets of autoimmune attack.[2] Thyrotropin receptor antibody binding sites have been demonstrated in pretibial fibroblasts, and, these may be stimulated to produce high amounts of hyaluronic acid. According to another theory, T cells that react with thyrotropin receptors on fibroblasts may cause cytokine-induced production of hyaluronic acid.[2]

Acropachy is a rare component of the triad, with an incidence of 0.8 to 1%. It can manifest up to 25 years after the onset of thyroid disease and may even appear after its treatment.[2] It is characterized by digital clubbing, periosteal bone proliferation, and soft tissue swelling.

Treatment of thyroid dermopathy includes steroids (topical, intralesional or under occlusion), compressive stockings,[3] pentoxifylline, gamma globulin, plasmapheresis, surgery and radiotherapy.[2] Recently octreotide, a somatostatin analog, was found to be effective in improving ophthalmopathy.[3] Acropachy, being asymptomatic, doesn′t require treatment. Partial or complete remission may occur in time.[3] Options for therapy include excision, hyaluronidase, local radiotherapy and topical potent steroids.[3]

References
1.
Rosen T, Kleman GA. Thyroid and the skin. In: Callen JP, editor. Dermatological signs of internal disease. 2nd Ed. Philadelphia: WB Saunders; 1995. p. 189-95.
[Google Scholar]
2.
Anderson CK, Miller OF. Triad of exophthalmos, pretibial myxedema and acropachy. J Am Acad Dermatol 2003;48:970-2.
[Google Scholar]
3.
Julia Ai, Leonlordt, Warren H, Janie M. Autoimmune thyroiditis etiology pathogenesis and dermatological manifestations, J Am Acad Dermatol 2003;48:641-59.
[Google Scholar]
4.
Weisman K, Graham RM. Systemic disease and the skin. In: Champion RH, Burton JL, Burns DA, Breathnach SM, editors. Rook-Wilkinson-Ebling Textbook of Dermatology, Vol 3. 6th Ed. London: Blackwell; 1998. p. 2703-18.
[Google Scholar]
5.
Freinkel RK. Other endocrine disorders. In: Freedberg IM, Eisen AZ, Wolff K, Austen FK, Goldsmith LA, Katz SI, et al. editors. Dermatology in internal medicine, 5th Ed. New York: McGraw Hill; 1999. p. 1976-8.
[Google Scholar]

Fulltext Views
358

PDF downloads
84
Show Sections