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Shaziya Kalam1, P S. S Ranugha1, Garehatty R Kanthraj1, Vijaya Basavaraj2
1 From the Department of Dermatology, Venereology and Leprosy, JSS Medical College and Hospital, JSSAHER, Mysore, Karnataka, India
2 Department of Pathology, JSS Medical College and Hospital, JSSAHER, Mysore, Karnataka, India
Correspondence Address:
P S. S Ranugha
Department of Dermatology, Venereology and Leprosy, JSS Medical College and Hospital, JSSAHER, Mysore, Karnataka
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijd.ijd_147_23
How to cite this article:Sir,
Pretibial myxedema (PTM) is an infrequent manifestation of Grave's disease, rarely seen in patients with Hashimoto thyroiditis, hypothyroidism, and euthyroidism, thus the name “Thyroid dermopathy.” Several therapeutic approaches have been tried in PTM with limited success. Our patient was a young male with unilateral PTM who showed a good response to intralesional steroids (ILS) with minimal recurrence on follow-up.
A 41-year-old male patient presented to our hospital with asymptomatic raised lesions on the right leg of 3 years duration. He was diagnosed with colloid goiter and Grave's disease 3 years ago and treated with near-total thyroidectomy followed by levothyroxine supplementation. The leg lesions have been the same since then. On examination, a large well-defined, firm plaque with an irregular surface, measuring 12 × 7 cm in diameter was present over the anterolateral aspect of the right leg [Figure 1]a. Histopathology was consistent with PTM [Figure 2]. He underwent eight sessions of ILS using triamcinolone acetonide (TA) over 4 months at two-week intervals – 20 mg/ml for the first two sessions and 40 mg/ml thereafter. TA had to be given beneath the lesion in the first few sessions due to the hard consistency. There was a significant decrease in size (8 × 7 cm) and thickness following the fourth session [Figure 1]b with no major adverse effects. This was followed by near complete resolution at the completion of treatment [Figure 1]c with minimal recurrence in three years of follow-up.
Figure 1: (a) Solitary plaque of PTM seen over the lateral aspect of the right leg at baseline, (b) Reduction seen after four sessions of ILS, (c) Complete remission after eight sessions of ILS. ILS = intralesional steroids, PTM = Pretibial myxedema
Figure 2: (a) Histopathology (hematoxylin and eosin stain) showed orthokeratosis and acanthosis of epidermis, loosely spaced collagen, few fibroblasts, and an increase in mucin in the dermis (10x magnification), (b) Histopathology (alcian blue stain) showed an increase in mucin in the dermis (40x magnification)PTM is a form of mucinosis commonly characterized by diffuse nonpitting oedema of the legs or feet. It can also appear as asymptomatic nodules or plaques with a peau d'orange appearance. The lesions are usually bilateral; unilateral presentation has been rarely reported in the literature.[1] Topical corticosteroid under occlusion has been found to be less effective when compared to intralesional in patients with long-standing disease.[2] The dosage and frequency of ILS can influence the efficacy of treatment. In the randomized controlled trial (RCT) by Lan et al.[3], TA (50 mg/5 ml) was used in two groups at intervals of 3 and 7 days for a total of seven injections each. Although remission was seen in 87–90% of cases in both, there were more adverse events with shorter intervals and recurrence in 32% of cases at 3.5 years follow-up. As we maintained an interval of 2 weeks, we did not encounter any local side effects, and there was a very minimal recurrence of the infiltration at 3 years of follow-up. Modifications like the addition of oral pentoxifylline to triamcinolone[4] and delivery of steroids by mesotherapy needles[5] have shown some success in severe PTM.
The natural course of PTM studied in 178 cases revealed spontaneous resolution in 50% within 17 years.[2] However, Endo et al.[6] observed worsening of preexisting lesions and the development of new lesions in an untreated case. Despite the probability of spontaneous remission in mild cases, this may happen after several years and may not be complete, and a better response is achieved if treated early. Therefore, it is imperative to initiate early treatment in cosmetically unacceptable lesions like nodules or plaques. We would like to suggest the use of ILS as the first line of treatment in long-standing plaques of PTM.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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