Surgical excision of pseudotumorous pretibial myxedema

Morphological Diversity of Pretibial Myxedema and Its Mechanism of Evolving Process and Outcome: A Retrospective Study of 216 Cases. J Thyroid Res. 2016;2016:2652174. [PMID: 27648339 PMCID: PMC5014960 DOI: 10.1155/2016/2652174]

Background. Pretibial myxedema (PTM) is a rare dermopathy. The morphologic features and mechanism of its evolving process are not reported in large case series. Methods. 216 cases with PTM were retrospectively reviewed to analyze demographics, history, lesional morphology and its evolving process, histopathology and immunohistochemistry, serum TRAb levels, treatment, and outcome. Results. First appearing lesions evolved into 6 variants that were correlated with serum TRAb levels. Subvariants were caused by different kinds and frequencies of local trauma. The evolving process could be classified into 4 stages that were correlated with serum TRAb levels and perivascular infiltration of CD8+ and CD4+ lymphocytes. Serum TRAb levels at remission and in nonrecurred cases became lower than those before therapy and in recurred cases, respectively, but increased when PTM relapsed. TRAb level in nodule variant went down invariably with the extension of course and its autoimmune activity had a trend to stop but in other 5 variants TRAb levels fluctuated. Their autoimmune activities had no trends to stop and clinically worsen through intermittent repeats of active and stable stages. Conclusions. In the chronic course of PTM, nodule variant is self-limited and other 5 variants are not self-limited. PTM needed early treatment to avoid severe variants.

Long-term follow-up and epidemiological trends in patients with pretibial myxedema: an 11-year study from a tertiary care center in northern India

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.

Thyroid dermopathy and acropachy

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.

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.