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Indian Journal of Dermatology
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INTERDISCIPLINARY PLATFORM
Year : 2006  |  Volume : 51  |  Issue : 2  |  Page : 96-99
Thyroid and skin


Department of Skin or VD and Deptt. of Endocrinology, Dayanand Medical College and Hospital, Ludhiana, India

Correspondence Address:
Alka Dogra
321, Dr. Sham Singh Road, Ludhiana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.26927

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   Abstract 

The association of thyroid disorders with skin manifestations is complex. Both hypothryoidism and hyperthyroidism are known to cause these changes. In order to study this association of skin changes in relation to hypothyroidism, a study was carried out in the outpatients department of Dermatology of Dayanand Medical College and Hospital, Ludhiana, over a period of 3 months from Jan-March 2005. Thirty two patients were enrolled in the study and parameters were noted regarding history, general symptoms, cutaneous signs and associated diseases. We found gain in weight (71.85%) and lethargy (65.62%) to be the most common complaints. On cutaneous examination, dry, coarse texture of the skin (56%), pigmentary disorders (37.5%) and telogen effluvium (40.62%) were the most common findings. Other associated disorders were vitiligo, melasma, pemphigus, alopecia areata, xanthelasma palpebrarum, etc.


Keywords: Cutaneous, Hypothyroidism, Pigmentary


How to cite this article:
Dogra A, Dua A, Singh P. Thyroid and skin. Indian J Dermatol 2006;51:96-9

How to cite this URL:
Dogra A, Dua A, Singh P. Thyroid and skin. Indian J Dermatol [serial online] 2006 [cited 2017 Nov 20];51:96-9. Available from: http://www.e-ijd.org/text.asp?2006/51/2/96/26927



   Introduction Top


Thyroid disorders are known to involve all the organ systems of the body and the skin is no exception. Both hypothyroidism and hyperthyroidism are known to cause skin changes. Hypothyroidism is clinically defined as an endocrinal state with TSH levels > 4.20 IU/ml; T3 < 3.95 pmol/lt and T4< 12.00 pmol/lt. The cutaneous manifestations of hypothyroid disease may be considered categorically as [Table - 1]:

1. Specific lesions.

2. Non specific signs related to hypothyroid state.

3. Other cutaneous or systemic conditions

associated with thyroid disease.

The precise diagnosis depends on history, physical examination and laboratory confirmation of the specific thyroid disorder. The present study was conducted in Dayanand Medical College and Hospital to evaluate the cutaneous changes in hypothyroid patients.


   Materials and Methods Top


The study was carried out in the out patients department of Dermatology in Dayanand Medical College and Hospital, Ludhiana over a period of 3 months from January - March 2005. The patients who had skin complaints (e.g., change in texture, pigmentation, xerosis, urticaria, etc.) and symptoms of thyroid disorders (weight change, palpitations, lethargy, menstrual problems) were evaluated for serum thyroid levels. Those patients who were diagnosed to be hypothyroid (TSH level > 4.20 IU/ml, T3 <3.95 pmol/it and T4<12.00 pmol/it) were taken up for the study. Some patients were referred from the endocrinology clinic who were known cases of hypothyroidism and were on treatment but whose serum TSH levels were raised at the time of inclusion in the study. A total of 32 patients were enrolled.

The parameters noted have been tabulated in [Table - 2].


   Observations and Results Top


A total of 32 patients of hypothyroidism were taken up for study. One had congenital hypothyroidism and 31 had adult onset hypothyroidism. Twenty eight patients were females and 4 males (female-male ratio 7:1). The average age of presentation was 39 yrs and 1 1/2 months. (range: 6 years - 60 years). The average serum thyroid levels were 53.95 IU/ml with a range of 7.91 to 100 IU/ml. Some patients were already on treatment for hypothyroidism. On haemogram analysis, 4 patients were found to be anemic.

History

The most common presenting complaint was gain in weight (n=23: 71.85%) followed by lethargy (n=21) and tachycardia.[1] Five patients complained of restlessness. Tremors of hands were seen in only 3 patients. Incidentally seven of our patients complained of increase in appetite.

Interestingly, we found pigmentary disorders to be a common presenting complaint. Four patients had diffuse hyperpigmentation of skin (which included face, arms, trunk and legs). Melasma was found in 6 patients. periocular pigmentation (Jelinek's sign) was found in 2 patients.

On cutaneous examination

The texture of the skin was found to be 'dry and coarse' in 18 patients (56%), which constituted the most common cutaneous sign [Table - 3].

The typical features of thyroid dermopathy were conspicuous by their absence although some evidence of pedal oedema (n=1) and thickening of skin (n=1) was found. Urticaria was found in 5 patients out of which 1 had acute urticaria and 4 patients had chronic urticaria. Nine patients complained of generalized pruritus (idiopathic cause).

Six patients complained of increased sweating. Thirteen patients characteristically had telogen effluvium. Three patients complained of leukonychia, and 1 of ragged cuticles and brittle nails.

Among associated diseases we found the following pattern: vitiligo (3); melasma (6); pemphigus vulgaris with Diabetes mellitus (1); cutaneous amyloidosis (1); xanthelasma palpabrarum (1); alopecia areata (1), androgenetic alopecia with seborrhea capitis (1); hypertension with seizure disorder (1); contact dermatitis (face) (1); tinea cruris and tinea corporis (2); echhymosis on forearm (1); skin tags (1).


   Discussion Top


In our study of 32 patients of hypothyroidism, one was of congenital hypothyrodism and 31 of adult onset. The female to male ratio was 7:1 which is almost the same as reported in other studies by Lanigan and Leznoff.[2],[3] Four patients were having microcytic hypochromic anaemia which is contrary to the usual association of hypothyrodism with pernicious anaemia.[4] Lethargy, restlessness and weakness were seen in 21 patients (65.5%), a feature quite commonly seen in hypothyroidism as reported by Levy.[1] Although decrease in appetite is expected in such patients due to low metabolic rate, 7 of our patients complained of increase in appetite. Menstrual abnormalities constituted a large chunk of complaints. Oligomenorrhea/amenorrhoea was the main complaint (10 patients: 31.25%) in these patients. Menstrual abnormalities are an expected complication seen with thyroid disorders as discussed by Thymas[6]; Bohnet[7] and Djrolof.[8] Cold intolerance was noticed in 10 patients (31.25%) with dry, cold and pale skin. Hypothermia is a result of hypometabolic state which causes reduced core temperature and reflex cutaneous vasoconstriction as reported by Mullin.[8],[9] Three patients of hypothyroidism also complained of heat intolerance but were on treatment and hence the discrepancy.

The texture of the skin in most of the patients (19 patients: 59.37%) was found to be dry. The xerosis was severe enough in some cases to be considered as an acquired icthyosis. Hypohidrosis accompanied by cytologic changes within the eccrine apparatus[10] and diminished sebaceous gland secretion have long been considered potential etiologic factors. A recent study of rats in which the thyroids have been removed demonstrated that diminished epidermal sterol biosynthesis may be pathogenic in the development of the ichthyosis observed in hypothyroidism.[11]

Hyperpigmentation in thyroid disorders has been reported mainly in hyperthyroidism.[12] Interestingly, we found pigmentary disorders - diffuse hyperpigmentation (n=4), melasma (n=6) and periocular pigmentation (n=2) - to be a very unusual common complaint in a total of 12 patients (37.5%). The explanation of hyperpigmentation in hyperthyroid patients is increased release of pituitary adrenocorticotropic hormone compensating for accelerated cortical degradation. In hypothyroidism though, the cause of melasma cannot be explained although it has been documented in literature.[13]

Leznoff and Sussman[2] evaluated 624 patients with idiopathic chronic urticaria and angioedema and found 90 patients to have evidence of thyroid disease. Five patients in our study had urticaria out of which 1 had acute urticaria and 4 had chronic urticaria. Heymann[14] has stated that the mechanism by which thyroid autoimmunity is associated with urticaria is poorly understood. They have stated that there is a clustering of thyroid microsomal antibodies in patients with a positive autologous serum test although it is unlikely that thyroid hormone itself has any in vivo effect on the cutaneous vascular response to histamine and on mast cell releasability.[15]

Thyroid dermopathy is said to be the most characteristic cutaneous sign of hypothyroidism which is characterised by generalised myxeodema caused by deposition of dermal acid mucopolysachharides especially hyaluronic acid and chondroitin sulphate.[5] Two of our patients had pedal oedema with thickening of skin.

Thirteen patients of hypothyroidism complained of telogen effluvium. The findings are similar to those found by Feingold[16] who has stated that the rate of hair growth is slowed. Alopecia of hypothydroidism is mediated via hormone effect on the initiation as well as duration of hair growth. Normal telogen - anagen hair relationships were restored with thyroid hormone replacements. The nails are thickened and brittle and grow slowly as is also evidenced in our study (n=2).

Associated diseases

Three patients presented with vitiligo, a finding similar to that of Block[17] as well. Six patients had melasma. The association has been well documented by Lufti[18] and Neipomniszcse.[13] One patient presented with pemphigus vulgaris (along with diabetes mellitus). Wolf and Fewermann[19] have repeatedly found the association of pemphigus group of disorders with thyroid disease. One patient in our study presented with alopecia areata. It is a known association which has been found a number of times in several studies.[20],[21]

Milgraum et al[21] found that in a study of 45 children with alopecia areata, 24% had an abnormality of one or more thyroid function tests (i.e., T4, T3, TSH and/AMA levels) although clinically most patients appeared normal. At least 2 patients had tinea cruris with corporis, as reported by Moreno et al .[22] They stated that locally altered cell mediated immunity might have predisposed the patient to dermatophytoses.


   Conclusion Top


With our limited experience, we have reached a conclusion that there definitely exists a strong association between cutaneous signs and symptoms with hypothyroidism. Though we found a varied pattern in the form of high incidence of pigmentary disorders and low incidence of thyroid dermopathy (which is said to be the hallmark of thyroid disease), nonetheless a high degree of suspicion must be kept in mind in patients presenting with such signs and symptoms to rule out an underlying thyroid disorder.

 
   References Top

1.Levy EG. Thyroid disease in the elderly. Med Clin North Am 1991;75:151-67.   Back to cited text no. 1  [PUBMED]  
2.Leznoff A, Sussman GL. Syndrome of Idiopathic chronic urticaria and angiodema with thyroid autoimmunity: A study of 90 patients. J Allergy Clin Immunol 1989;84:66-71.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Amoraso A, Garzia P, Pasquarelli C, Sportelli G, Afeltra A. Hashimoto's Thyroiditis associated with urticaria and angioedema: Disappearance of cutaneous and mucosal manifestation after thyroidectomy. J Clin Pathol 1997;50:254-6.   Back to cited text no. 3    
4.Hanna FW, Lazarus JH, Scanlon MF. Controversial aspect of thyroid disease. BMJ 1999;319:894-9.   Back to cited text no. 4    
5.Heymann WR. Cutaneous manifestation of thyroid disease. J Am Acad Dermatol 1992;26:85-902.   Back to cited text no. 5    
6.Thomas R, Reid RC. Thyroid disease and reproductive dysfunction. Obstet Gynaecol 1987;70:789-98.   Back to cited text no. 6    
7.Bohnet HG, Fiedler K, Leidenberger FA. Subclincal hypothyroidism and infertitiy. Lancet 1981;2:1278.   Back to cited text no. 7    
8.Diorole F, Houngbe F, Attolou V, Houtond Quenim K, Hountondji A. Hypothyroidism: Clinical and etiological aspects in Gotonou. Sante 2001;11:245-9.   Back to cited text no. 8    
9.Mullin GE, Eastern JS. Cutaneous signs of thyroid disease. Am Fam Phys 1986;34:93-8.   Back to cited text no. 9    
10.Means MA, Dobson RL. Cytological changes in the sweat gland in hypothyroidism. JAMA 1963;186:113-5.   Back to cited text no. 10    
11.Oppenheimer JH, Schwartz HL, Lane JT, Thompson MP. Functional relationship of thyroid hormone-induced lipogenesis, lipolysis and thermogenesis in the rat. J Clin Invest 1991;87:125-32.   Back to cited text no. 11    
12.Mullin GE, Eastern JS. Cutaneous consequences of accelerated thyroid function. Cutis 1986;37:109-14.   Back to cited text no. 12    
13.Niepomniszcse H, Amad RH. Skin disorders and thyroid diseases. Endocrinol Invest 2001;24:628-38.   Back to cited text no. 13    
14.Heymann WR. Chronic Urticaria and angioedema associated with thyroid autoimmunity; Review and therapeutic implications. J Am Acad Dermatol 1999;40:229-32.   Back to cited text no. 14    
15.Rumbyrt JS, Katz JL, Schock AL . Resolution of chronic urticaria in patients with thyroid autommunity. J Allergy Clin Immunol 1995;96:901-5.   Back to cited text no. 15    
16.Feingold KR, Elias PM. Endocrine Skin interactions. J Am Acad Dermatol 1987;17:921-40.   Back to cited text no. 16    
17.Block MH, Sowers JR. Vitiligo and polyglandular autoimmune endocrinopathy. Cutis 1985;36:417-9.   Back to cited text no. 17    
18.Luffi RJ, Fridmanis M, Misiunas AL, Pafume O, Gonzalez EA, Villemur JA, et al . Association of melasma with thyroid autommunity and other thyroid abnormalities and their relationship to the origin of Melasma. J Clin Endocrinol Metab 1985;61:28-31.   Back to cited text no. 18    
19.Wolf R, Fewerman EJ. Pemphigus in association with antiommune thyroid disease. Cutis 1981;24:423-4.   Back to cited text no. 19    
20.Milgraum SS, Mitchel AJ, Bacon GE, Rasmussen JE. Alopecia areata endocrine function and autoantibodies in patients 16 years of age or younger. J Am Acad Dermatol 1987;97:57-61.   Back to cited text no. 20    
21.Tosti A, Bardazzi F, Guerra L. Alopecia areata and thyroid function Letter. J Am Acad Dermatol 1988;19:1118-9.  Back to cited text no. 21    
22.Moreno AJ, Hartshorne MF, Yedinak MA, Crooks LA, Fox BJ. Tinea corporis overlying thyroid gland after radio-iodine treatment of Grave's disease. Cutis 1986;37:271-3.  Back to cited text no. 22    


    Tables

[Table - 1], [Table - 2], [Table - 3]

This article has been cited by
1 Alteraciones dermatológicas asociadas a hipotiroidismo
Victoria Alcázar Lázaro,Antonio Aguilar Martínez
Endocrinología y Nutrición. 2013; 60(6): 345
[Pubmed] | [DOI]
2 Skin changes associated to hypothyroidism
Victoria Alcázar Lázaro,Antonio Aguilar Martínez
Endocrinología y Nutrición (English Edition). 2013; 60(6): 345
[Pubmed] | [DOI]



 

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