eMedicine Specialties > Dermatology > Metabolic Diseases

Pretibial Myxedema: Differential Diagnoses & Workup

Author: 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
Coauthor(s): Laurel R Stearns, DO, Resident in Dermatology, National Capital Consortium; Kathryn K Garner, MD, Staff Physician, Department of Family Medicine, Martin Army Community Hospital, Fort Benning, Georgia
Contributor Information and Disclosures

Updated: Apr 24, 2008

Differential Diagnoses

Amyloidosis, Lichen
Insect Bites
Lichen Myxedematosus
Lichen Planus
Lichen Simplex Chronicus
Stasis Dermatitis

Other Problems to Be Considered

Collagen-vascular disorders
Generalized pruritus (possibly severe with Graves disease)
Stasis mucinosis
Sweet syndrome

Workup

Laboratory Studies

  • Thyrotropin levels may be abnormally high or low, depending on whether the underlying thyroid disease has been recognized and treated.
  • LATS levels are elevated in about 50% of patients with PTM.

Histologic Findings

The characteristic histopathologic features consist of the deposition of mucin (glycosaminoglycans) throughout the reticular dermis and with attenuation of collagen fibers. Mucin may appear as individual threads and granules. With extensive deposition of mucin, the collagen fibers are frayed, fragmented, and widely separated. Stellate fibroblasts are often observed, but the number of fibroblasts is not increased. The overlying epidermis may show hyperkeratosis. The mucin is hyaluronic acid that stains blue with Alcian-blue at a pH of 2.5 and colloidal iron stains (see Media File 3); metachromasia is shown with toluidine blue stain. Findings of mucin deposition restricted to an expanded papillary dermis, nodular angioplasia, and hemosiderin deposition are more suggestive of stasis dermatitis.

More on Pretibial Myxedema

Overview: Pretibial Myxedema
Differential Diagnoses & Workup: Pretibial Myxedema
Treatment & Medication: Pretibial Myxedema
Follow-up: Pretibial Myxedema
Multimedia: Pretibial Myxedema
References
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References

  1. 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].

  2. 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. Sep 1995;105(3):372-8. [Medline].

  3. Fatourechi V, Bartley GB, Eghbali-Fatourechi GZ, Powell CC, Ahmed DD, Garrity JA. Graves' dermopathy and acropachy are markers of severe Graves' ophthalmopathy. Thyroid. Dec 2003;13(12):1141-4. [Medline].

  4. Missner SC, Ramsay EW, Houck HE, Kauffman CL. Graves' disease presenting as localized myxedema in a thigh donor graft site. J Am Acad Dermatol. Nov 1998;39(5 Pt 2):846-9. [Medline].

  5. 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. Nov 2007;21(10):1441-3. [Medline].

  6. Engin B, Gümüsel M, Ozdemir M, Cakir M. Successful combined pentoxifylline and intralesional triamcinolone acetonide treatment of severe pretibial myxedema. Dermatol Online J. May 1 2007;13(2):16. [Medline].

  7. Antonelli A, Navarranne A, Palla R, Alberti B, Saracino A, Mestre C, et al. Pretibial myxedema and high-dose intravenous immunoglobulin treatment. Thyroid. Winter 1994;4(4):399-408. [Medline].

  8. 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. Jul 1994;131(1):52-6. [Medline].

  9. 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. Nov 2000;143(5):1083-6. [Medline].

  10. 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. May 2003;13(5):465-70. [Medline].

  11. Felton J, Derrick EK, Price ML. Successful combined surgical and octreotide treatment of severe pretibial myxoedema reviewed after 9 years. Br J Dermatol. Apr 2003;148(4):825-6. [Medline].

  12. Fatourechi V, Pajouhi M, Fransway AF. Dermopathy of Graves disease (pretibial myxedema). Review of 150 cases. Medicine (Baltimore). Jan 1994;73(1):1-7. [Medline].

  13. Heymann WR. Advances in the cutaneous manifestations of thyroid disease. Int J Dermatol. Sep 1997;36(9):641-5. [Medline].

  14. Kriss JP. Pathogenesis and treatment of pretibial myxedema. Endocrinol Metab Clin North Am. Jun 1987;16(2):409-15. [Medline].

  15. Malkinson FD, Furey N. Pretibial myxedema. Arch Dermatol. Dec 1967;96(6):737-8. [Medline].

  16. Schwartz KM, Fatourechi V, Ahmed DD, Pond GR. Dermopathy of Graves' disease (pretibial myxedema): long-term outcome. J Clin Endocrinol Metab. Feb 2002;87(2):438-46. [Medline].

  17. Smith TJ, Bahn RS, Gorman CA. Connective tissue, glycosaminoglycans, and diseases of the thyroid. Endocr Rev. Aug 1989;10(3):366-91. [Medline].

  18. Somach SC, Helm TN, Lawlor KB, Bergfeld WF, Bass J. Pretibial mucin. Histologic patterns and clinical correlation. Arch Dermatol. Sep 1993;129(9):1152-6. [Medline].

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Further Reading

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Keywords

PTM, thyroid dermopathy, Graves disease, hyaluronic acid, thyroid ophthalmopathy, thyroid disease

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Contributor Information and Disclosures

Author

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, and Association of Military Dermatologists
Disclosure: Nothing to disclose.

Coauthor(s)

Laurel R Stearns, DO, Resident in 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.

Kathryn K Garner, MD, Staff Physician, Department of Family Medicine, Martin Army Community Hospital, Fort Benning, Georgia
Kathryn K Garner, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Physicians, and Uniformed Services Academy of Family Physicians
Disclosure: Nothing to disclose.

Medical Editor

Gregory J Raugi, MD, PhD, Professor, Department of Internal Medicine, Division of Dermatology, University of Washington at Seattle; 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.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: 3M Pharmaceutical Grant/research funds Other; Graceway Pharmaceuticals Grant/research funds Other

Managing Editor

Christen M Mowad, MD, Associate Professor, Department of Dermatology, Geisinger Medical Center
Christen M Mowad, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

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