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Pretibial Myxedema Clinical Presentation

  • Author: Ranjodh Singh Gill, MD, FACP, CCD; Chief Editor: Dirk M Elston, MD  more...
Updated: Feb 02, 2016


The onset of pretibial myxedema (PTM) most commonly occurs 1-2 years after the diagnosis of Graves disease, but it may occur before or after the onset of thyrotoxicosis. PTM in the absence of Graves disease is uncommon. Most patients who develop PTM also have Graves ophthalmopathy, with the onset of dermopathy typically following the onset of ophthalmopathy by 6-12 months. The natural history of PTM is not well defined. Available data indicate that about 10-26% of patients eventually experience complete remission, and about 24% have partial remission. Rare cases of PTM without ophthalmology have been recorded.[5, 6]

Skin lesions or areas of non-pitting edema appear on the anterior or lateral aspects of the legs or in sites of old or recent trauma in patients with Graves disease.

Otherwise unexplained skin lesions or areas of non-pitting edema occur in patients with thyroid disease.




A retrospective analysis of pretibial myxedema (PTM) patients revealed that the pretibial area was most commonly involved (99%), nonpitting edema was the most common form of dermopathy (43%), and the majority of patients had coexisting ophthalmopathy (96%).[7]

[8] Thyroid acropachy occurs in 1% of patients with Graves disease. It is clinically characterized by clubbing of the fingers and the toes, periosteal proliferation of the shafts of the phalanges and other distal long bones, and swelling of the soft tissues overlying affected bony structures. When present, acropachy usually follows dermopathy. Graves dermopathy and acropachy appear to be markers of severe ophthalmopathy. See the image below.

Bilateral erythematous infiltrative plaques in theBilateral erythematous infiltrative plaques in the pretibial areas.

Early lesions are bilateral, firm, nonpitting, asymmetrical plaques or nodules. Hair follicles are sometimes prominent, giving a peau d'orange texture. Areas of nonpitting edema may develop. In the elephantiasic form of PTM, lesions may coalesce to give the entire extremity an enlarged, verruciform appearance. Overlying hyperhidrosis or hypertrichosis may be present in these cases.

Lesions characteristically appear on the lateral or anterior aspect of the legs, but they may occur on the thighs,[9] the shoulders, the hands, the forehead, or any other skin surface. Lesions often occur in areas of recent or prior trauma or skin graft donor sites.

Lesions are characteristically shiny pink to purple-brown.



Pretibial myxedema (PTM) is generally considered a cutaneous manifestation of thyroid disease.

Contributor Information and Disclosures

Ranjodh Singh Gill, MD, FACP, CCD Associate Professor of Medicine, Division of Endocrinology, Virginia Commonwealth University School of Medicine and McGuire Veterans Administration Medical Center; Consulting Staff, Department of Internal Medicine, Virginia Commonwealth University Health System

Ranjodh Singh Gill, MD, FACP, CCD is a member of the following medical societies: American Association of Physicians of Indian Origin, American College of Physicians, Endocrine Society, International Society for Clinical Densitometry, Medical Society of Virginia, North American Sikh Medical and Dental Association, Richmond Academy of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Christen M Mowad, MD Professor, Department of Dermatology, Geisinger Medical Center

Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, Noah Worcester Dermatological Society, Pennsylvania Academy of Dermatology, American Academy of Dermatology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Gregory J Raugi, MD, PhD Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle School of Medicine; Chief, Dermatology Section, Primary and Specialty Care Service, Veterans Administration Medical Center of Seattle

Gregory J Raugi, MD, PhD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

George E vonHilsheimer, MD Assistant Professor of Dermatology, Uniformed Services University of the Health Sciences; Chief, Staff Dermatologist, Department of Medicine, Martin Army Community Hospital, Fort Benning, Georgia

George E vonHilsheimer, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists

Disclosure: Nothing to disclose.

Kathryn K Garner, MD Staff Physician, Family Health Clinic, Ehrling Bergquist Clinic, Offutt AFB, NE

Kathryn K Garner, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Physicians, Uniformed Services Academy of Family Physicians

Disclosure: Nothing to disclose.


Purnima Sau, MD Associate Professor, Department of Clinical Dermatology, Uniformed Services University of the Health Sciences

Disclosure: Nothing to disclose.

Laurel R Stearns, DO ResidentPhysician, Department of Dermatology, National Capital Consortium

Laurel R Stearns, DO is a member of the following medical societies: American Academy of Dermatology and Association of Military Osteopathic Physicians and Surgeons

Disclosure: Nothing to disclose.

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Bilateral erythematous infiltrative plaques in the pretibial areas.
Deposition of mucin in the reticular dermis (hematoxylin and eosin stain, original magnification X25).
Blue staining of mucin with colloidal iron stain (original magnification X25).
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