Pretibial Myxedema Clinical Presentation
- Author: Ranjodh Singh Gill, MD, FACP, CCD; Chief Editor: Dirk M Elston, MD more...
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%).
 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.
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, 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.
Doshi DN, Blyumin ML, Kimball AB. Cutaneous manifestations of thyroid disease. Clin Dermatol. 2008 May-Jun. 26 (3):283-7. [Medline].
Kamath C, Young S, Kabelis K, Sanders J, Adlan MA, Furmaniak J, et al. Thyrotrophin receptor antibody characteristics in a woman with long-standing Hashimoto's who developed Graves' disease and pretibial myxoedema. Clin Endocrinol (Oxf). 2012 Sep. 77(3):465-70. [Medline].
Komosinska-Vassev K, Winsz-Szczotka K, Olczyk K, Kozma EM. Alterations in serum glycosaminoglycan profiles in Graves' patients. Clin Chem Lab Med. 2006. 44(5):582-8. [Medline].
Heufelder AE, Bahn RS, Scriba PC. Analysis of T-cell antigen receptor variable region gene usage in patients with thyroid-related pretibial dermopathy. J Invest Dermatol. 1995 Sep. 105(3):372-8. [Medline].
Subramanyam S, Lohiya V, Stahl EJ. Pretibial Myxedema Without Ophthalmopathy: An Initial Presentation of Graves' Disease. Am J Med Sci. 2013 Mar 19. [Medline].
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 Aug. 54 (8):e280-6. [Medline].
Schwartz KM, Fatourechi V, Ahmed DD, Pond GR. Dermopathy of Graves' disease (pretibial myxedema): long-term outcome. J Clin Endocrinol Metab. 2002 Feb. 87(2):438-46. [Medline].
Fatourechi V, Bartley GB, Eghbali-Fatourechi GZ, Powell CC, Ahmed DD, Garrity JA. Graves' dermopathy and acropachy are markers of severe Graves' ophthalmopathy. Thyroid. 2003 Dec. 13(12):1141-4. [Medline].
Missner SC, Ramsay EW, Houck HE, Kauffman CL. Graves' disease presenting as localized myxedema in a thigh donor graft site. J Am Acad Dermatol. 1998 Nov. 39(5 Pt 2):846-9. [Medline].
Ai J, Leonhardt JM, Heymann WR. Autoimmune thyroid diseases: etiology, pathogenesis, and dermatologic manifestations. J Am Acad Dermatol. 2003 May. 48 (5):641-59; quiz 660-2. [Medline].
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 Nov. 7 (11):862-72. [Medline].
Ramos LO, Mattos PC, Figueredo GL, Maia AA, Romero SA. Pre-tibial myxedema: treatment with intralesional corticosteroid. An Bras Dermatol. 2015 Jun. 90 (3 Suppl 1):143-6. [Medline].
Pineda AM, Tianco EA, Tan JB, Casintahan FA, Beloso MB. Oral pentoxifylline and topical clobetasol propionate ointment in the treatment of pretibial myxoedema, with concomitant improvement of Graves' ophthalmopathy. J Eur Acad Dermatol Venereol. 2007 Nov. 21(10):1441-3. [Medline].
Türke B, Balázs C. [Treatment of pretibial myxoedema with pentoxifylline]. Orv Hetil. 2012 Oct 28. 153(43):1719-22. [Medline].
Engin B, Gümüsel M, Ozdemir M, Cakir M. Successful combined pentoxifylline and intralesional triamcinolone acetonide treatment of severe pretibial myxedema. Dermatol Online J. 2007 May 1. 13(2):16. [Medline].
Antonelli A, Navarranne A, Palla R, Alberti B, Saracino A, Mestre C, et al. Pretibial myxedema and high-dose intravenous immunoglobulin treatment. Thyroid. 1994 Winter. 4(4):399-408. [Medline].
Priestley GC, Aldridge RD, Sime PJ, Wilson D. Skin fibroblast activity in pretibial myxoedema and the effect of octreotide (Sandostatin) in vitro. Br J Dermatol. 1994 Jul. 131(1):52-6. [Medline].
Shinohara M, Hamasaki Y, Katayama I. Refractory pretibial myxoedema with response to intralesional insulin-like growth factor 1 antagonist (octreotide): downregulation of hyaluronic acid production by the lesional fibroblasts. Br J Dermatol. 2000 Nov. 143(5):1083-6. [Medline].
Rotman-Pikielny P, Brucker-Davis F, Turner ML, Sarlis NJ, Skarulis MC. Lack of effect of long-term octreotide therapy in severe thyroid-associated dermopathy. Thyroid. 2003 May. 13(5):465-70. [Medline].
Felton J, Derrick EK, Price ML. Successful combined surgical and octreotide treatment of severe pretibial myxoedema reviewed after 9 years. Br J Dermatol. 2003 Apr. 148(4):825-6. [Medline].
Deng A, Song D. Multipoint subcutaneous injection of long-acting glucocorticid as a cure for pretibial myxedema. Thyroid. 2011 Jan. 21(1):83-5. [Medline].
Takasu N, Higa H, Kinjou Y. Treatment of pretibial myxedema (PTM) with topical steroid ointment application with sealing cover (steroid occlusive dressing technique: steroid ODT) in Graves' patients. Intern Med. 2010. 49(7):665-9. [Medline].