eMedicine Specialties > Dermatology > Metabolic Diseases
Pretibial Myxedema: Treatment & Medication
Updated: Apr 24, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- The lesions of PTM are primarily of cosmetic concern, although severe elephantiasic forms may lead to significant limb enlargement and impair function.
- Surgical treatment should be avoided because scarring may aggravate the dermopathy, and benefits are equivocal.
- Local application of corticosteroids remains the mainstay of treatment.
- Compression wraps or stockings that provide 20-40 mm Hg of pressure can be useful as an adjunctive therapy.
Consultations
- Consult a dermatologist for an evaluation of lesions in suspected PTM.
- Consult an endocrinologist for an evaluation of possible underlying thyroid disease.
Medication
Various medical treatments, including plasmapheresis and cytotoxic therapy, have been tried, but the efficacy of these therapies is unproven. Intralesional or topical therapy with corticosteroids is currently the only treatment that offers demonstrated efficacy. Systemic use should be avoided because of undesirable adverse effects.
Combinations reported as helpful include oral pentoxifylline and topical clobetasol propionate ointment5 and pentoxifylline with intralesional triamcinolone acetonide.6
Newer treatment regimens that are promising but require further investigation include octreotide, a somatostatin analog, and high-dose intravenous immunoglobulin (IVIG).7 The basis for use of octreotide stems from research of refractory PTM patients who had increased expression of insulinlike growth factor-1 receptor on up-regulated fibroblasts. Intralesional injections of octreotide have led to decreased amounts of hyaluronic acid within the lesion. Some studies report success with weekly injections, and patients have remained symptom free for up to 15 months8,9 ; however, others do not.10 Surgical removal is generally ill advised because scarring may worsen dermopathy; however, at least one patient with thick plaques prior to surgical shaving of the lesion and daily octreotide injections for 6 months did not have recurrence after 9 years of surveillance.11
Corticosteroids
These agents are applied topically under an occlusive dressing, and they provide symptomatic relief in many patients. A variety of ointments, creams, and gels are available. The following are a few examples of topical preparations available (in order of decreasing potency).
Betamethasone (Diprolene)
For inflammatory dermatoses responsive to steroids. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Affects production of lymphokines and has inhibitory effect on Langerhans cells. Use 0.05% cream or ointment. Similar potency to clobetasol and halobetasol.
Adult
Apply thin film to affected areas bid until lesions resolve or 4-6 wk of treatment have passed
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; paronychia; cellulitis; impetigo; angular cheilitis; erythrasma; erysipelas; rosacea; perioral dermatitis; acne
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use on skin with decreased circulation; can cause atrophy of groin, face, and axillae; if infection develops and is not responsive to antibiotic treatment, discontinue until infection is under control; do not use monotherapy to treat widespread plaque psoriasis
Fluocinonide (Fluonex, Lidex)
High-potency topical corticosteroid that inhibits cell proliferation; is immunosuppressive and anti-inflammatory. Use 0.05% ointment or gel. Similar potency to mometasone and fluticasone.
Adult
Apply sparingly to affected areas bid and cover with occlusive dressing until lesions resolve or 4-6 wk have passed; plastic wrap may be used for occlusive dressing
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; herpes simplex infection; fungal, viral, or tubercular skin lesions
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause adverse systemic effects if used over large areas, on denuded areas, on occlusive dressings, or during prolonged treatment periods
Hydrocortisone (LactiCare HC, Westcort, Dermacort, DermaGel, Cortaid)
An adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Has mineralocorticoid and glucocorticoid effects resulting in anti-inflammatory activity.
Adult
Apply sparingly to affected areas bid
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; viral, fungal, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Products may contain either tartrazine or sodium bisulfite, which may cause allergic reactions in susceptible individuals; prolonged use, application over large surface areas, and use of potent steroids and occlusive dressings may increase systemic absorption of corticosteroids and may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
Triamcinolone (Kenalog)
For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Use 0.1% ointment.
Adult
Apply thin film bid/tid until favorable response obtained
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; fungal, viral, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use on skin with decreased circulation; prolonged use, application over large areas, and use of potent steroids and occlusive dressings may result in systemic absorption and may cause Cushing syndrome, reversible HPA-axis suppression, hyperglycemia, and glycosuria
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
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. Sep 1995;105(3):372-8. [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. Dec 2003;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. Nov 1998;39(5 Pt 2):846-9. [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. Nov 2007;21(10):1441-3. [Medline].
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].
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].
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].
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].
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].
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].
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].
Heymann WR. Advances in the cutaneous manifestations of thyroid disease. Int J Dermatol. Sep 1997;36(9):641-5. [Medline].
Kriss JP. Pathogenesis and treatment of pretibial myxedema. Endocrinol Metab Clin North Am. Jun 1987;16(2):409-15. [Medline].
Malkinson FD, Furey N. Pretibial myxedema. Arch Dermatol. Dec 1967;96(6):737-8. [Medline].
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].
Smith TJ, Bahn RS, Gorman CA. Connective tissue, glycosaminoglycans, and diseases of the thyroid. Endocr Rev. Aug 1989;10(3):366-91. [Medline].
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].
Further Reading
Keywords
PTM, thyroid dermopathy, Graves disease, hyaluronic acid, thyroid ophthalmopathy, thyroid disease
