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Hathi D, Goswami S, Sengupta N, Baidya A, Gaikwad PM, Das N, Tarenia SS, Oswal R. A Case of Elephantiasic Pretibial Myxedema Successfully Treated With Intralesional Triamcinolone Acetate. Cureus 2022; 14:e29234. [PMID: 36259012 PMCID: PMC9573773 DOI: 10.7759/cureus.29234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/19/2022] Open
Abstract
Graves' dermopathy is one of the extra-thyroidal manifestations of Graves’ disease (GD) and is characterized by the accumulation of glycosaminoglycans in the reticular dermis. In the majority of cases, pretibial myxedema is self-limiting but, in some cases, it can lead to structural and functional damage. Topical steroids with occlusive dressing remain the conventional treatment, but intralesional steroids have shown promising results. We hereby present a case of pretibial myxedema treated successfully with intralesional triamcinolone acetate.
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Dauguet M, Abba S, Lebrun-Vignes B, Vignes S. Des lésions végétantes des jambes. Rev Med Interne 2022; 43:450-451. [DOI: 10.1016/j.revmed.2022.03.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/20/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022]
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Mir SUI, Laway BA. Elephantiatic Graves' Dermopathy Successfully Treated with Intralesional Steriod. Indian J Endocrinol Metab 2021; 25:471-472. [PMID: 35300437 PMCID: PMC8923328 DOI: 10.4103/ijem.ijem_367_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sajad Ul Islam. Mir
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Bashir A. Laway
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Du T, Jiang W, Luo H, Chen F, Yuan G, Zhang M, Liu Z. Bilateral breast myxedema caused by Graves' disease and responsive to multipoint subcutaneous injection of long-acting glucocorticoid: Case report. Medicine (Baltimore) 2021; 100:e26469. [PMID: 34160454 PMCID: PMC8238392 DOI: 10.1097/md.0000000000026469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/07/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE With the absence of ophthalmopathy, thyroid dermopathy especially lesions at atypical locations is a very rare presentation. We herein report an original case of bilateral breast myxedema caused by Grave's disease. PATIENT CONCERNS A 21-year-old unmarried woman presented with a 4-month history of Grave's disease and a 1-month history of progressive bilateral breast enlargement. She had symmetrical bilateral breast enlargement with redness and nonpitting thickening of the skin, diffusely enlarged thyroid glands, and no exophthalmos. DIAGNOSIS Ultrasonography, magnetic resonance imaging scan, and skin biopsy confirmed the diagnosis of bilateral breast myxedema. INTERVENTIONS The patient was treated with multipoint subcutaneous injections of triamcinolone acetonide in each breast every month. OUTCOMES The bilateral breast returned approximately to its normal size after therapy for 6 months. CONCLUSIONS Our case illustrates that multipoint subcutaneous injection of glucocorticoids is beneficial for bilateral breast myxedema.
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Affiliation(s)
- Tingting Du
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, Branch of National Clinical Research Center for Metabolic Disease, Hubei
| | - Wangyan Jiang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, Branch of National Clinical Research Center for Metabolic Disease, Hubei
| | - Hongchang Luo
- Department of Ultrasonography, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fuqiong Chen
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, Branch of National Clinical Research Center for Metabolic Disease, Hubei
| | - Gang Yuan
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, Branch of National Clinical Research Center for Metabolic Disease, Hubei
| | - Muxun Zhang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, Branch of National Clinical Research Center for Metabolic Disease, Hubei
| | - Zhelong Liu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China, Branch of National Clinical Research Center for Metabolic Disease, Hubei
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Zhang F, Lin XY, Chen J, Peng SQ, Shan ZY, Teng WP, Yu XH. Intralesional and topical glucocorticoids for pretibial myxedema: A case report and review of literature. World J Clin Cases 2018; 6:854-861. [PMID: 30510955 PMCID: PMC6265002 DOI: 10.12998/wjcc.v6.i14.854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/04/2018] [Accepted: 10/11/2018] [Indexed: 02/05/2023] Open
Abstract
Pretibial myxedema (PTM), an uncommon manifestation of Graves’ disease (GD), is a local autoimmune reaction in the cutaneous tissue. The treatment of PTM is a clinical challenge. We herein report on a patient with PTM who achieved complete remission by multipoint subcutaneous injections of a long-acting glucocorticoid and topical glucocorticoid ointment application for a self-controlled study. A 53-year-old male presented with a history of GD for 3.5 years and a history of PTM for 1.5 years. Physical examination revealed slight exophthalmos, a diffusely enlarged thyroid gland, and PTM of both lower extremities. One milliliter of triamcinolone acetonide (40 mg) was mixed well with 9 mL of 2% lidocaine in a 10 mL syringe. Multipoint intralesional injections into the skin lesions of the right lower extremity were conducted with 0.5 mL of the premixed solution. A halometasone ointment was used once daily for PTM of the left lower extremity until the PTM had remitted completely. The patient’s PTM achieved complete remission in both legs after an approximately 5-mo period of therpy that included triamcinolone injections once a week for 8 wk and then once a month for 2 mo for the right lower extremity and halometasone ointment application once daily for 8 wk and then once 3-5 d for 2 mo for the left lower extremity. The total dosage of triamcinolone acetonide for the right leg was 200 mg. Our experience with this patient suggests that multipoint subcutaneous injections of a long-acting glucocorticoid and topical glucocorticoid ointment application are safe, effective, and convenient treatments. However, the topical application of a glucocorticoid ointment is a more convenient treatment for patients with PTM.
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Affiliation(s)
- Fan Zhang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Xin-Yue Lin
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Jian Chen
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Shi-Qiao Peng
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Zhong-Yan Shan
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Wei-Ping Teng
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Xiao-Hui Yu
- Department of Endocrinology and Metabolism, Institute of Endocrinology, Liaoning Provincial Key Laboratory of Endocrine Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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Corvilain B, Hamy A, Brunaud L, Borson-Chazot F, Orgiazzi J, Bensalem Hachmi L, Semrouni M, Rodien P, Lussey-Lepoutre C. Treatment of adult Graves' disease. ANNALES D'ENDOCRINOLOGIE 2018; 79:618-635. [PMID: 30193753 DOI: 10.1016/j.ando.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Treatment strategy in Graves' disease firstly requires recovery of euthyroid status by antithyroid therapy. Treatment modalities, precautions, advantages and side-effects are to be discussed with the patient. No particular treatment modality has demonstrated superiority. Pregnancy or pregnancy project affects choice of treatment and monitoring. Graves' orbitopathy is liable to be aggravated by iodine-131 treatment and requires pre-treatment assessment. Iodine-131 treatment aims at achieving hypothyroidism. Thyroid surgery for Graves' disease should preferably be performed by an expert team. In case of recurrence of hyperthyroidism, the various treatment options should be discussed with the patient. Empiric treatment of thyroid dermopathy uses local corticosteroids in occlusive dressing.
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Affiliation(s)
- Bernard Corvilain
- Department of Endocrinology, Erasme University Hospital, université Libre de Bruxelles, Brussels, Belgium
| | - Antoine Hamy
- Service de chirurgie viscérale et endocrine, CHU d'Angers, 49000 Angers, France
| | - Laurent Brunaud
- Service de chirurgie, unité de chirurgie endocrinienne, thyroïdienne et métabolique, unité multidisciplinaire de chirurgie de l'obésité, université de Lorraine, CHU Nancy, hôpital Brabois adultes, 11, allée du Morvan, 54511 Vandœuvre-les-Nancy, France
| | - Françoise Borson-Chazot
- HESPER EA 7425, hospices civils de Lyon, fédération d'endocrinologie, université Claude-Bernard Lyon 1, 69008 Lyon, France
| | - Jacques Orgiazzi
- CERMEP-imagerie du vivant, université Claude-Bernard Lyon 1, Lyon, France
| | - Leila Bensalem Hachmi
- Service d'endocrinologie à l'Institut national de nutrition de Tunis, faculté de médecine de Tunis, Tunisia
| | | | - Patrice Rodien
- Service EDN, centre de référence des maladies rares de la thyroïde et des récepteurs hormonaux, CHU d'Angers, 49000 Angers, France.
| | - Charlotte Lussey-Lepoutre
- Service de médecine nucléaire, Inserm U970, Sorbonne université, groupe hospitalier Pitié-Salpétrière, 75013 Paris, France
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Vannucchi G, Salvi M. Pretibial Myxedema. ENCYCLOPEDIA OF ENDOCRINE DISEASES 2018:707-710. [DOI: 10.1016/b978-0-12-801238-3.65245-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Ren Z, He M, Deng F, Chen Y, Chai L, Chen B, Deng W. Treatment of pretibial myxedema with intralesional immunomodulating therapy. Ther Clin Risk Manag 2017; 13:1189-1194. [PMID: 28932121 PMCID: PMC5598751 DOI: 10.2147/tcrm.s143711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective Local immune regulation therapy has been one of the therapeutic methods used for the treatment of autoimmune thyroid disease in patients with pretibial myxedema (PTM). However, the poor response rate and high recurrence rate are still major problems. Whether a premixed corticosteroid, compound betamethasone, could enhance remission rate and decrease recurrence rate in patients with PTM was investigated in the present study. Subjects and methods We have performed a clinical utility observation of compound betamethasone with intralesional injections based on basic thyroid disease treatment in 32 PTM patients between January 2008 and August 2016. The patients were followed up for 2 years, and the clinical outcomes and side effects were calculated and analyzed. Results All patients had a complete remission after different times of injection. A total of 21.7% patients had complete remission with one time of injection, 34.8% with two times of injection, 17.4% with three times of injection, 4.3% with four times of injection, and 4.3% with five times of injection. In all, 56.3% patients with a disease duration of <6 months had complete remission after a 1-month treatment, 37.5% patients with a disease duration between 6 months and 12 months had complete remission after a 2-month treatment, 3.1% patients with a disease duration of 2 years had complete remission after a 5-month treatment, and 3.1% with a disease duration of 5 years had complete remission after a 7-month treatment. Conclusion Compound betamethasone with multipoint intralesional injection is a feasible, effective, and secure novel strategy in the treatment of PTM.
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Affiliation(s)
- Ziwei Ren
- Department of Endocrinology and Nephrology, Chongqing Emergency Medical Hospital (The Fourth People's Hospital of Chongqing)
| | - Min He
- Department of Endocrinology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China
| | - Fang Deng
- Department of Endocrinology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China
| | - Yan Chen
- Department of Endocrinology and Nephrology, Chongqing Emergency Medical Hospital (The Fourth People's Hospital of Chongqing)
| | - Liyin Chai
- Department of Endocrinology and Nephrology, Chongqing Emergency Medical Hospital (The Fourth People's Hospital of Chongqing)
| | - Bing Chen
- Department of Endocrinology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China
| | - Wuquan Deng
- Department of Endocrinology and Nephrology, Chongqing Emergency Medical Hospital (The Fourth People's Hospital of Chongqing)
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Huang Y, Wei C, Ma S, Fu Y, Xu W. Response of a Patient with Severe Thyroid Dermopathy to Combined Multipoint Subcutaneous Injection of Glucocorticoids and Local Excision. Thyroid 2016; 26:753-5. [PMID: 26971589 DOI: 10.1089/thy.2015.0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Yingshi Huang
- 1 Health Care Center, First Affiliated Hospital of Shantou University Medical College , Shantou, China
| | - Chiju Wei
- 2 Biomedical Sciences and Advanced Materials Research Center, Shantou University , Shantou, China
| | - Shuhua Ma
- 3 Radiology Department, First Affiliated Hospital of Shantou University Medical College , Shantou, China
| | - Yucai Fu
- 4 Pathogenic Biology Department, Shantou University Medical College , Shantou, China
| | - Wencan Xu
- 5 Endocrinology Department, First Affiliated Hospital of Shantou University Medical College , Shantou, China
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Ramos LO, Mattos PC, Figueredo GLPD, Maia AAA, Romero SAR. Pre-tibial myxedema: treatment with intralesional corticosteroid. An Bras Dermatol 2016; 90:143-6. [PMID: 26312698 PMCID: PMC4540532 DOI: 10.1590/abd1806-4841.20153651] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 06/03/2014] [Indexed: 12/11/2022] Open
Abstract
The pretibial myxedema is a manifestation of Graves' disease characterized by
accumulation of glycosaminoglycans in the reticular dermis. The dermopathy is
self-limiting but in some cases may cause cosmetic and functional damage.
Conventional treatment is use of topical steroids under occlusive dressing, however
the intralesional application has shown good results. We present a case of pretibial
myxedema treated with single injection of intralesional corticosteroid.
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Lan C, Li C, Chen W, Mei X, Zhao J, Hu J. A Randomized Controlled Trial of Intralesional Glucocorticoid for Treating Pretibial Myxedema. J Clin Med Res 2015; 7:862-72. [PMID: 26491499 PMCID: PMC4596268 DOI: 10.14740/jocmr2303w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pretibial myxedema (PTM) is an uncommon dermopathy associated with autoimmune thyroid diseases. Now it is thought to be autoimmune and its treatment with glucocorticoid is helpful. However, it has not been evaluated. METHODS A prospective randomized controlled trial was performed in 110 patients with PTM to evaluate the efficacy and safety of triamcinolone acetonide with intralesional injection once every 3 days and once every 7 days. Randomization was performed with drawing lots and it was also stratified according to variants of PTM lesions. In the follow-up, recurrent rates were observed. The SPSS Statistics 17.0 Software was used in the statistical analysis. RESULTS The complete response rates were 78.2%, 83.6%, and 87.3% in regimen 1 and 50.9%, 89.1%, and 90.9% in regimen 2 at 3 weeks, 7 weeks and the end of therapy, respectively. Regimen 1 had an earlier efficacy than regimen 2, but at 7 weeks and end of therapy, there were no differences between two regimens. The majority of non-severe variants got complete response but severe variants did not. The adverse reaction rates in regimen 1 were higher and earlier than those in regimen 2. Adverse reaction occurring time in regimen 1 was shorter than that in regimen 2. Recurrent rates were 31.25% and 32% in regimens 1 and 2 at 3.5-year follow-up. CONCLUSIONS For its autoimmune, hyperplasia and disabled features, early treatment of PTM with glucocorticoid is necessary to get complete response. Dosage and frequency of intralesional steroid injection and lesional variants influence the efficacy of PTM. Once every 7 days is a better regimen.
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Affiliation(s)
- Changgui Lan
- Department of Dermatology, China National Nuclear Corporation 416 Hospital, No.4, Er Huan Lu Bei Si Duan, Chengdu City, Sichuan Province, China
| | - Can Li
- Department of Dermatology, China National Nuclear Corporation 416 Hospital, No.4, Er Huan Lu Bei Si Duan, Chengdu City, Sichuan Province, China
| | - Wei Chen
- Department of Dermatology, China National Nuclear Corporation 416 Hospital, No.4, Er Huan Lu Bei Si Duan, Chengdu City, Sichuan Province, China
| | - Xiaofeng Mei
- Department of Dermatology, China National Nuclear Corporation 416 Hospital, No.4, Er Huan Lu Bei Si Duan, Chengdu City, Sichuan Province, China
| | - Jing Zhao
- Department of Dermatology, China National Nuclear Corporation 416 Hospital, No.4, Er Huan Lu Bei Si Duan, Chengdu City, Sichuan Province, China
| | - Jie Hu
- Department of Dermatology, China National Nuclear Corporation 416 Hospital, No.4, Er Huan Lu Bei Si Duan, Chengdu City, Sichuan Province, China
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Sendhil Kumaran M, Dutta P, Sakia U, Dogra S. Long-term follow-up and epidemiological trends in patients with pretibial myxedema: an 11-year study from a tertiary care center in northern India. Int J Dermatol 2015; 54:e280-6. [PMID: 26019115 DOI: 10.1111/ijd.12658] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 11/14/2013] [Accepted: 01/20/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Pretibial myxedema (PTM) is a rare manifestation of Graves' disease. There is paucity of data regarding long-term follow-up and response to treatment in PTM. MATERIALS AND METHODS Retrospective study wherein 30 patients of PTM presenting during 2001-2011 attending dermatology and endocrinology outpatient departments were analyzed. RESULTS Among 30 patients with PTM, 12 were males and 18 females with a ratio of 1 : 1.5 males/females. Four morphological forms were identified: plaques (18 patients), diffuse non-pitting edema of both lower legs (five), nodules (five), and elephantiasis lesions (two). Eighty percent were diagnosed with hyperthyroidism before the development of dermopathy. Twenty-six patients presented with ophthalmopathy. Fourteen patients with plaque had an excellent response to topical clobetasol propionate ointment and attained complete resolution by 3.6 years. Out of 16 patients treated with combination therapy, which included nine treated with topical corticosteroids/intralesional triamcinolone and seven treated with oral, intralesional, and topical corticosteroids, nine attained complete resolution in the lesions by 3.4 years, and none relapsed anytime during four years of post-treatment follow-up. However, the remaining patients (elephantiasis and diffuse forms) failed to achieve complete resolution. CONCLUSIONS Plaques and nodules are common variants with a favorable clinical response to topical and intralesional corticosteroid; elephantine and diffuse forms responded poorly to therapy. Studies analyzing larger cohorts of patients with PTM and their long-term follow-up are limited, hence more such studies are required.
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Affiliation(s)
- Muthu Sendhil Kumaran
- Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Uma Sakia
- Department of Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Dogra
- Department of Dermatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Bartalena L, Fatourechi V. Extrathyroidal manifestations of Graves' disease: a 2014 update. J Endocrinol Invest 2014; 37:691-700. [PMID: 24913238 DOI: 10.1007/s40618-014-0097-2] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 05/20/2014] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Graves' orbitopathy (GO), thyroid dermopathy (also called pretibial myxedema) and acropachy are the extrathyroidal manifestations of Graves' disease. They occur in 25, 1.5, and 0.3 % of Graves' patients, respectively. Thus, GO is the main and most common extrathyroidal manifestation. Dermopathy is usually present if the patient is also affected with GO. The very rare acropachy occurs only in patients who also have dermopathy. GO and dermopathy have an autoimmune origin and are probably triggered by autoimmunity to the TSH receptor and, likely, the IGF-1 receptor. Both GO and dermopathy may be mild to severe. MANAGEMENT Mild GO usually does not require any treatment except for local measures and preventive actions (especially refraining from smoking). Currently, moderate-to-severe and active GO is best treated by systemic glucocorticoids, but response to treatment is not optimal in many instances, and retreatments and use of other modalities (glucocorticoids, orbital radiotherapy, cyclosporine) and, in the end, rehabilitative surgery are often needed. Dermopathy is usually managed by local glucocorticoid treatment. No specific treatment is available for acropachy. PERSPECTIVES Novel treatments are presently being investigated for GO, and particular attention is paid to the use of rituximab. It is unknown whether novel treatments for GO might be useful for the other extrathyroidal manifestations. Future novel therapies shown to be beneficial for GO in randomized studies may be empirically used for dermopathy and acropachy.
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Affiliation(s)
- Luigi Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Viale Borri, 57, 21100, Varese, Italy.
| | - Vahab Fatourechi
- Department of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA.
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Kim WB, Mistry N, Alavi A, Sibbald C, Sibbald RG. Pretibial Myxedema: Case Presentation and Review of Treatment Options. INT J LOW EXTR WOUND 2014; 13:152-154. [PMID: 24807996 DOI: 10.1177/1534734614531485] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pretibial myxedema (PM) is a rare autoimmune manifestation of Graves' disease, which commonly presents as diffuse, nonpitting edema of shins and less often as plaques, nodules, or elephantiasis lesions mimicking lymphedema. We present a 57-year-old woman with 12-month history of PM, which occurred a year after treatment of Graves' disease and improved with topical corticosteroids, support stockings, and intralesional steroid injections until recurrence with local erythema and woody edema. A literature review was undertaken of the evidence-based treatment modalities for symptomatic PM: although commonly asymptomatic and self-limited, severe cases of PM may be treated with topical corticosteroid, compressive therapy, and intralesional corticosteroid injections.
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Affiliation(s)
- Whan B Kim
- McMaster University, Hamilton, Ontario, Canada
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Vannucchi G, Campi I, Covelli D, Forzenigo L, Beck-Peccoz P, Salvi M. Treatment of pretibial myxedema with dexamethazone injected subcutaneously by mesotherapy needles. Thyroid 2013; 23:626-32. [PMID: 23397966 DOI: 10.1089/thy.2012.0429] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Pretibial myxedema (PTM) is a rare extrathyroidal manifestation of Graves' disease that requires treatment when the clinical picture is markedly evident. In addition to topical treatment with steroid ointments, there have been previous reports of subcutaneous injections of steroids. This procedure may cause nodular degeneration of the skin due to fat atrophy when standard needles are used. In the present study, we have tried a novel modality of treatment of PTM by injecting a solution of dexamethasone in the subcutaneous tissue using needles employed for mesotherapy. These needles are ≤4 mm long and deliver the medication within the dermis or the first layer of the subcutaneous fat. We have treated five patients, four with diffuse and one with elephanthiasic PTM. We utilized multiple injections of a solution of dexamethasone, lidocaine, and saline in the PTM plaque and in the pretibial area, both in the PTM plaque and in the area surrounding the lesions, once a week for three consecutive weeks. Two patients with a more severe form of PTM underwent another two cycles four to six weeks after initial treatment. Patients were studied before and after treatment by clinical assessment and ultrasound of the pretibial skin. The treatment was well-tolerated, with only moderate pain upon injection of the solution. One month after treatment, all patients showed improvement of PTM at clinical assessment and a reduction of the thickness of the lesions at ultrasound of ∼15%, involving mostly the dermis. Moreover, all patients reported amelioration of the leg appearance. The present study, although preliminary, shows that intralesion steroid injection with mesotherapy needles in PTM is effective and well tolerated, and does not cause undesired long-term modifications of the skin. More studies are warranted to standardize such treatment in larger groups of patients.
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Affiliation(s)
- Guia Vannucchi
- Endocrine Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione Cà Granda IRCCS, Milan, Italy.
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Abstract
Graves' disease is an autoimmune condition commonly associated with thyroid dysfunction and with anti-thyroid antibodies, usually TSH receptor stimulating antibodies. Thyroid autoimmunity also may be associated with extra thyroidal manifestations. Most common extra thyroidal manifestation is ophthalmopathy. Less common is thyroid dermopathy, usually occurring in pretibial area. Dermopathy is almost always associated with ophthalmopathy and in severe cases with acropachy. A common antigen with thyroid in tissues of the skin and the eyes, most likely TSH receptor, is involved in pathogenesis of extra thyroidal manifestations. Presence of dermopathy and acropachy are predictors of severity of autoimmune process. Local corticosteroid application is the standard therapy for dermopathy. Response to therapy is good in mild cases and poor in severe cases. Immune modulators and biotherapies are undergoing randomized trials for ophthalmopathy component of Graves' disease. Any therapy proven to be effective for ophthalmopathy can be utilized in future for management of dermopathy.
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Affiliation(s)
- Vahab Fatourechi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First ST SW, Rochester, MN, USA.
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