By Gary M. White, MD
Peau d'orange surface on the shins.
Pretibial myxedema is a thickening of the skin, usually over the shins, caused by cutaneous infiltration by glycosaminoglycans, mainly hyaluronic acid, and is usually associated with thyroid disease. Almost all patients have high levels of thyroid stimulating antibodies. Rarely, pretibial myxedema may occur in the euthyroid patient or in those hypothyroid. The vast majority of patients also have ophthalmopathy which may be severe, to the point of requiring decompressive surgery. Clubbing of the fingers (part of thyroid acropachy) may be associated. Thyroid-stimulating hormone receptor antibodies (TRAb) are the principal autoantibodies and are able to stimulate the proliferation and glycosaminoglycan metabolism of fibroblasts in vitro.
Skin-colored or red-brown plaques of the pretibial area often with a surface peau d'orange appearance in a hyperthyroid patient are characteristic. Various clinical forms have been described including non-pitting edema (most common), plaque form, the nodular form and the elephantiasic form (rare). Lesions may occur on the hands or elsewhere. The average age in one study was 53 with a female to male ratio of 3.5:1 (This corresponds to the patient population with Graves' disease.) Hyperhidrosis localized to the area has been seen [JAAD 1990;23;250].
Referral to an ophthalmologist is in order. Observation only is appropriate. Spontaneous resolution may occur. A high potency topical steroid with or without occlusion may be tried. If this fails, IL triamcinolone e.g. 5-10 mg/cc may help. The thyroid status should be evaluated and treated if needed. Rarely, gradient pneumatic compression [AD 1994;130;842], plasmapheresis [BMJ 1979;1;374], cytotoxic therapy [Cleve Clin Q 1983;50;183], or octreotide [BJD 1994;131;52] have been used.
One study recommended the triple therapy combination of topical glucocorticoid under occlusion, intralesional steroid injection and high-dose ultraviolet 1 phototherapy [Acta Dermato-Venereologica 2016 ahead of print].
Complete decongestive physiotherapy may be performed for elephantiasic pretibial myxedema [JAAD 2002;46;723]. This approach is not a cure, but a method for long term control in the compliant patient. Daily massage to mobilize fluid and multilayered compressive bandages are key parts of CDP.
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