Monday, February 27, 2012

Causes Of Myxedema

Myxedema (Adult hypothyroidism) is caused by an accumulation of tissue products, such as glycosaminoglycans, in the skin. Myxedema is almost always a result of hypothyroidism. Specific causes of hypothyroidism that can lead to myxedema include Hashimoto’s thyroiditis, thyroidectomy (surgical removal of the thyroid), and Graves’ disease.

The most common cause of hypothyroidism is inflammation of the thyroid gland, which damages the gland's cells. Autoimmune or Hashimoto's thyroiditis, in which the immune system attacks the thyroid gland, is the most common example of this. Some women develop hypothyroidism after pregnancy (often referred to as "postpartum thyroiditis").

Other common causes of hypothyroidism include:
  • Congenital (birth) defects
  • Radiation treatments to the neck to treat different cancers, which may also damage the thyroid gland
  • Radioactive iodine used to treat an overactive thyroid (hyperthyroidism)
  • Surgical removal of part or all of the thyroid gland, done to treat other thyroid problems
  • Viral thyroiditis, which may cause hyperthyroidism and is often followed by temporary or permanent hypothyroidism
Certain drugs can cause hypothyroidism, including:
  • Amiodarone
  • Drugs used for hyperthyroidism (overactive thyroid), such as propylthiouracil (PTU) and methimazole
  • Lithium
  • Radiation to the brain
  • Sheehan syndrome, a condition that may occur in a woman who bleeds severely during pregnancy or childbirth and causes destruction of the pituitary gland.
A number of factors increase the risk of developing myxedema. Not all people with risk factors will get myxedema.

Risk factors for myxedema include:
  • Age over 50 years
  • Autoimmune disorders (diseases in which the immune system attacks the body’s own tissues as foreign substances)
  • Current or previous hypothyroidism
  • Female gender

Sunday, February 26, 2012

Myxedema Pictures Face

Myxedema Pictures Face
Myxedema Pictures Face

Adult woman with the characteristic puffiness that often accompanies hypothyroidism. Her puffiness and hair texture markedly improve after treatment with desiccated thyroid.

Myxedema Pictures Face
Myxedema Pictures Face, Image source:

This is another example of the resolution of the puffiness (myxedema) following proper treatment of hypothyroidism with desiccated thyroid.

Pretibial Myxedema Picture

Pretibial Myxedema Picture

Swelling of the lower legs brought this 57-year-old woman to a family practice clinic. She had a history of hyperthyroidism with weight loss, tachycardia, and anxiety. This condition was confirmed with blood tests and radioactive iodine(Drug information on iodine) uptake testing. Pretibial myxedema is a classic finding in hyperthyroidism that may appear years before or after development of the endocrine disorder. The distinguishing feature is nonpitting edema of mucinous ground substance on the anterior surface of the lower leg. In the early stages, the overlying skin is erythematous and pruritic. These symptoms usually subside spontaneously over a period of months or years, but topical corticosteroids may be given to relieve the pruritus.

Saturday, February 25, 2012

Myxedema Coma Treatment

Myxedema Coma Treatment

The patient with myxedema coma should be admitted to the intensive care unit, and hypovolemia and electrolyte abnormalities corrected. Mechanical ventilation may be necessary. Cardiovascular status should be monitored carefully, especially after intravenous thyroid hormone replacement. Myocardial infarction must be ruled out and blood pressure stabilized. If possible, pressors and ionotropes should be avoided because of their tendency to provoke arrhythmias in the setting of intravenous thyroid replacement. Patients with hypothermia should be covered with regular blankets; the use of warming blankets should be avoided because the resulting peripheral dilatation may lead to hypotension and cardiovascular collapse.

Thyroid Hormone Replacement
Any patient with suspected myxedema coma should be treated presumptively with thyroid hormone. While there is concern regarding the precipitation of arrhythmias or myocardial infarction by administering large doses of intravenous levothyroxine, this concern must be balanced against T4's potentially life-saving and usually nondetrimental effect.

While the necessity of intravenous thyroid hormone replacement is apparent, some controversy exists regarding the use and dosages of levothyroxine (T4) and liothyronine (T3). Because of the relatively small number of patients with myxedema coma, controlled studies comparing various dosages of T4 and T3 are lacking. Because T3 is more biologically active than T4, and because the conversion of T4 to T3 is suppressed in myxedema coma, some have advocated T3 replacement. However, parental T3 is not only expensive and difficult to obtain, it may also contribute to increased mortality.

Most authorities therefore recommend use of T4 alone. An initial levothyroxine dose of 100 to 500 μg administered intravenously should be followed by 75 to 100 μg administered intravenously daily until the patient is able to take oral replacement. The lower initial dose should be administered to patients who are frail or have other comorbidities, particularly cardiovascular disease. Elderly patients typically require 100 to 170 μg of oral levothyroxine daily.

Infection is often the cause of the patient's decompensation; therefore, an infectious etiology should be sought with blood and urine cultures as well as a chest radiograph. Some authorities advocate empiric therapy with broad-spectrum intravenous antibiotics.

Because of the possibility of secondary hypothyroidism and associated hypopituitarism, hydrocortisone should be administered until adrenal insufficiency has been ruled out. Hydrocortisone should be administered intravenously at a dosage of 100 mg every eight hours. Failure to treat with hydrocortisone in the face of adrenal insufficiency may result in the precipitation of adrenal crisis. A random cortisol level should be drawn prior to therapy, and if not depressed, the hydrocortisone can be discontinued without tapering. An adrenocorticotropic hormone stimulation test can be administered if clinically warranted.

The prognosis for patients with myxedema coma is difficult to define because of the small number of cases reported in the literature. The severity of the condition, however, is clear. One study reported a mortality rate of about 30 percent, while another suggests the mortality rate may be as high as 60 percent. Factors associated with a poor prognosis include advanced age, bradycardia and persistent hypothermia.

Final Comment
Family physicians should be alert for myxedema coma, particularly in elderly women with mental status changes who present during the winter months. An accurate diagnosis generally follows a careful history, physical examination and laboratory evaluation. The most important elements in treatment of myxedema coma are early recognition, presumptive thyroid hormone replacement, hydrocortisone and appropriate supportive care. While myxedema coma carries a significant mortality rate even with appropriate testing and treatment, an early diagnosis of hypothyroidism may well save a patient's life.


Pretibial Myxedema Photo

Pretibial Myxedema Pictures
Pretibial myxedema photo
Image source:

Pretibial Myxedema images

Pretibial myxedema photo
Image source:

Thyroid dermopathy (localized myxedema) in five patients. A, Nonpitting edema form in pretibial area. B, Plaque form in pretibial area. C, Nodular form in ankle and foot. D, Elephantiasic form. E, Occurrence of thyroid dermopathy in scar tissue.

Friday, February 24, 2012

Treatment For Myxedema

Myxedema Coma Treatment Self-Care at Home

If you have hypothyroidism, be alert to your condition.
  • Call your doctor if you are concerned.
  • Check your blood sugar level if you are diabetic.
  • Warm yourself up with a warm blanket and seek help.
  • Take your prescribed thyroid medication if you missed them earlier.
People with myxedema coma are in a coma or nearly in a coma. They are not able to function normally. Friends or family members should take them to an emergency department immediately. Friends or family members should not give the person in myxedema coma any thyroid medication before taking him or her to the emergency department. If adrenal insufficiency is present, then administration of thyroxin (in the thyroid medication) will provoke an adrenal crisis.

Medical Treatment
  • Intravenous fluids
  • Electrolytes replacement as necessary
  • Thyroid hormones are usually administered through a vein (intravenously or IV) to quickly correct the low thyroid hormone blood level. (Oral thyroid hormone is usually not used for severe myxedema because it may take days or weeks to obtain the proper blood level.)
  • Cortisol or other adrenal cortical hormone intravenously
  • Warming blanket if body temperature is low
  • Glucose supplements if the blood sugar level is low
  • Antibiotics if an infection is present

Symptoms of Myxedema

What are the symptoms of myxedema?

Symptoms of myxedema include thickening of the skin and other symptoms associated with hypothyroidism, including fatigue, weight gain, depression, dry skin, and brittle hair, among others. Skin thickening or swelling associated with myxedema is often described as nonpitting edema. In other words, if you press on the skin of the affected area and then remove your finger, you will not see an imprint.

More serious associated symptoms include puffiness in the hands and face and slowing of speech. Rarely, serious or life-threatening symptoms, such as slowed breathing, low body temperature, or unresponsiveness, may be a sign of myxedema coma.

Common symptoms of myxedema
  • Myxedema is usually part of a larger group of symptoms associated with hypothyroidism. At times any of these symptoms can be severe and include:
  • Brittle hair or fingernails
  • Constipation
  • Decreased sweating
  • Depression
  • Dry or pale skin
  • Fatigue
  • Malaise or lethargy
  • Musculoskeletal pain
  • Sensitivity to cold
  • Thickening of the skin
  • Weakness (loss of strength)
  • Weight gain
Rare or serious symptoms of myxedema

Other symptoms occur more rarely with myxedema, but may indicate a specific cause, type, or more serious condition. These symptoms include:
  • Decreased senses of taste and smell
  • Fullness in the neck (a mass in the neck, called a goiter, is a very rare symptom)
  • Thinning of hair, including eyebrows
  • Slowed speech
Serious symptoms that might indicate a life-threatening condition

In some cases, myxedema can be life threatening. Seek immediate medical care (call 911) if you, or someone you are with, have any of these life-threatening symptoms including:
  • Change in level of consciousness or alertness, such as passing out or unresponsiveness
  • Chest pain
  • Difficulty breathing or decreased rate of breathing
  • Low blood sugar (hypoglycemia)
  • Low body temperature (hypothermia)

Thursday, February 23, 2012

Define Myxedema

Define Myxedema:

Myxedema is a condition marked by thickening and swelling of the skin caused by insufficient production of thyroid hormones by the thyroid gland. The function of thyroid hormones is to regulate your metabolism. Myxedema is associated with other symptoms of underactive thyroid, also called hypothyroidism, including lethargy, weight gain, fatigue, depression, and cold sensitivity, among others.

Hypothyroidism is more common in women, especially those over the age of 50, and can be caused by a viral infection, certain medications, radiation exposure, autoimmune disease, or inherited or congenital disorders. Myxedema is caused by hypothyroidism and occurs more frequently when hypothyroidism is left untreated. Your health care professional can order simple blood tests to determine whether you have hypothyroidism, which can lead to myxedema.

Depending on the cause, myxedema can be treated with thyroid replacement hormones. These medications are effective in eliminating the symptoms that accompany myxedema and hypothyroidism. If you are prescribed thyroid replacement medications, you will probably need to take them for the rest of your life. Left untreated, myxedema can have serious or, rarely, life-threatening complications.

Seek immediate medical care (call 911) for serious symptoms, including very low body temperature, difficulty breathing, low blood sugar, or difficulty thinking clearly, or if you are being treated for hypothyroidism and experience chest pain or heart palpitations.
Seek prompt medical care if you are being treated for myxedema but have mild symptoms that recur or are persistent.

Myxedema Treatment

The disease is frequently addressed by curing Hypothyroidism, which is its underlying cause and leads to the coarseness and thickening of the skin. The most common treatment involves substituting the reduced thyroid hormones with medications. When administered in appropriate doses, drugs may help stop the progression of the condition altogether.
Treatment of underlying hypothyroidism, which acts as the cause of myxedema, is the most essential part of therapy. However, there also exist other forms of treatment that aim at alleviating the symptoms of the condition. These include:
  • Topical corticosteroids – These may be used to reduce the inflammation occurring due to the thickening of skin caused by the disorder.
  • Compression stockings – These are also useful in decreasing the swelling arising due to this condition.
  • Thyroid replacement hormones – Thyroid hormone supplementation can effectively decrease inflammation and other symptoms arising from Myxedema and underlying hypothyroidism. However, its use depends on the underlying cause of the disorder. However, care should be taken to avoid excessive thyroid hormone replacement as it may cause hyperthyroidism symptoms like sweating, cardiac palpitations and rapid weight loss.
Although thyroid hormone supplementation is considered, thyroid replacement medications are not generally considered for treatment as patients need to use them for the rest of their life.
In cases where patients suffer from autoimmune disorders like Hashimoto’s Thyroiditis, blood monitoring may be needed more or less constantly to ensure that thyroid hormone levels remain within normal ranges.
Treatment measures, other than hormone replacement, should include:
  • Antibiotics, if infection is present
  • Electrolyte replacement
  • Glucose supplementation, particularly in case of low blood sugar
  • IV therapy
  • Steroid medications

Wednesday, February 22, 2012

Myxedema Symptoms

The disorder is initially characterized by various discomforting symptoms, such as:
  • Constipation
  • Depression
  • Fatigue
  • Hoarseness of voice
  • Intolerance to cold
  • Muscular aches
  • Thinning of hair
In the later stages, suffering individuals typically display other discomforting signs like:
  • Weight gain
  • Slow speech
  • Pale skin
  • Swelling of leg (edema)
  • Muscular cramps
  • Shortness of breath
  • Absence of sweat
  • Secretion of milk from breast
  • Loss of hearing sensations
  • Reduced taste sensations
  • Lowered sense of smell
  • Absence of menstrual periods
  • Rise in menstrual bleeding
The symptoms of Myxedema involving the skin are usually present along with other signs of low thyroid hormones. People with persistent cases of reduced thyroid hormone levels generally suffer from:
  • Easy weight gain
  • Loss of memory
  • Mental confusion
  • Muscular pain
  • Severe fatigue
The symptoms of Myxedema can be too difficult to endure. The condition has a significant impact on the skin which turns coarser and thicker. It generally becomes dryer and retains some amount of water. The skin may also change color to become yellow or orange in appearance. Additionally, there may be deposition of a certain “jellylike” material under some areas the skin. These deposits can lead to inflammation of the skin. In some cases, the disease only impacts the legs and may be referred to as “Partial”. More frequently, however, it affects the entire body thus causing:
  • Prominent inflammation
  • Roughness of the skin, particularly around the soles of the feet, elbows, knees and palms


Hypothyroidism picture
Image source:

What is hypothyroidism?

Hypothyroidism is a condition in which the thyroid gland does not produce enough thyroid hormone. Too little hormone slows down chemical reactions in the body. This slowdown causes mental and physical changes.

The thyroid gland is located at the lower front of the neck. This gland takes iodine from the food you eat to make hormones called thyroxine (T4) and triiodothyronine (T3). The hormones control your metabolism (the process of turning the food you eat into energy). The thyroid gland is critical for maintaining body temperature and controlling heart rate, appetite, and digestive tract function. Too little hormone may cause you to gain weight. Also, your heartbeat slows down and your body temperature gets lower. Food moves through your intestines more slowly and your muscles contract more slowly.

How Hypothyroidism occur?

Causes of hypothyroidism include:
  • Hashimoto's disease (thyroiditis): This condition is an inflammation of the thyroid gland. It is a disorder of your immune system (your body's protection against infection).
  • Thyroid surgery for complete or partial removal of the thyroid gland
  • Viruses: They can infect the thyroid gland and cause it to produce too little hormone. These infections do not usually cause permanent hypothyroidism.
  • Radiation treatment for hyperthyroidism (an overactive thyroid gland): Radioactive iodine is commonly used to treat an overactive thyroid gland. Radioactivity often destroys the gland and its ability to make thyroid hormone. When this happens, the body needs synthetic thyroid hormone.
  • People who have had X-ray treatment for cancers of the head and neck may develop hypothyroidism if their thyroid was exposed to radiation during the cancer treatment.
  • Iodine deficiency (rare): A lack of iodine in the diet is rare in the US because some foods, especially salt, contain added iodine.
  • Medicines used to treat hyperthyroidism, such as lithium, or a dosage of antithyroid medicine that is too high
  • Problem with the pituitary gland (rare): The pituitary gland normally stimulates the thyroid gland to produce hormones. The pituitary may fail to cause the thyroid gland to make enough hormone to meet your body's needs.
  • Congenital hypothyroidism (rare): Some people are born either without thyroid glands or with glands that cannot make thyroid hormone.
Anyone can have hypothyroidism, but it happens most often in women over age 40. Some thyroid problems are inherited.

What are Hypothyroidism symptoms?

The gradual slowing of your body's processes can take months or even years, making it hard for you to recognize the disease.
Symptoms of hypothyroidism include:
  • fatigue
  • depression
  • muscle weakness
  • constipation
  • weight gain
  • feeling cold a lot of the time
  • coarse, dry hair
  • thick, dry skin
  • swollen eyelids
  • deep, hoarse voice
  • thick tongue
  • thickened facial features
  • slowed heart rate
  • decreased sexual interest
  • loss of hearing
  • numb and tingling hands.
A condition that develops after several years of untreated hypothyroidism is called myxedema. Myxedema can cause you to become cold, slow to talk and move, and possibly drowsy. You might even fall into a coma.

How is Hypothyroidism diagnosed?

Your healthcare provider will ask about your symptoms and examine you. If your provider thinks that you may have hypothyroidism, you will have blood tests. The tests will measure the levels of thyroid hormone and your pituitary's thyroid-stimulating hormone (TSH). TSH causes your thyroid gland to make thyroid hormone.

How is Hypothyroidism treated?

Your healthcare provider will prescribe synthetic thyroid hormone medicine. You will most likely need to take the medicine every day for the rest of your life.

Most people need only small doses to replace their gland's normal output. After starting treatment, your healthcare provider will repeat the blood tests to be sure you are taking enough thyroid hormone. It may take several weeks to find the right dosage for you. Once the correct dosage is found, you will need to check your thyroid hormone level every few months.

If you have coronary artery disease or are at risk for it, your provider will prescribe a smaller dose of hormone tablets at first. Replacing thyroid hormone too quickly can worsen coronary artery disease and, in some cases, can prompt a heart attack. Women prone to osteoporosis may have greater bone loss if they take too much thyroid hormone. For this reason your thyroid hormone blood level will be checked periodically for the rest of your life to make sure it is in the correct, normal range.

How long will the effects last?

Usually hypothyroidism improves within a week after hormone therapy is begun. All symptoms go away within a few weeks. In most cases, however, you must continue this treatment for the rest of your life.

Mild hypothyroidism may cause no symptoms. If the disease progresses, however, it can become disabling over a long time if it is not treated. Untreated hypothyroidism may cause the following problems:
  • enlargement of the heart and heart failure (rare)
  • slowing of mental processes
  • loss of consciousness.
If the cause of hypothyroidism is thyroiditis and it is not treated, your thyroid gland may swell. This swelling, called a goiter, may cause a big bulge in your neck.

How can I take care of myself?

Many people with hypothyroidism, especially older adults, don't seek medical treatment because they don't know they have a problem. They may accept their symptoms of fatigue, muscle weakness, dry skin, depression, feeling cold, and constipation as signs of aging. If you notice some of the symptoms of hypothyroidism, see your healthcare provider.

When you have hypothyroidism, be sure to:
  • Follow your provider's instructions for taking your medicine.
  • Get your thyroid hormone level checked when your provider suggests.
  • Keep your follow-up appointments.
  • See you provider if your symptoms come back.
What can be done to help prevent hypothyroidism?

Except in the case when it is caused by a lack of iodine in the diet, hypothyroidism cannot be prevented.

Tuesday, February 21, 2012

Myxedema Madness

Myxedema, the medical term for hypothyroidism, is most commonly recognized by well-known physical symptoms: weight gain, puffiness about the face, dry skin, fatigue and a general slowing of the metabolism. However, the emotional signs and symptoms are quite often overlooked. Or, even more disturbingly, are attributed to non-existent mental health and psychiatric conditions.

Myxedema Madness is a catchall phrase, coined by Dr. Richard Asher in 1940, that encompasses a broad swath of emotions ranging from minor anxieties, doubts and worries to full-blown panic attacks and classic psychiatric conditions like schizophrenia. Myxedema Madness typically manifests as a simple bout of depression and is often treated as such, with antidepressants and advice to, "Slow down - take it easy for a bit." Unfortunately, neither the pills nor the pontification strike at the root of the issue.

If let untreated, Myxedema Madness can quickly devolve into a deadly serious condition. Minor anxieties may give way to major psychoses, delusions, hallucinations and paranoia. An otherwise affable person may snap at the slightest annoyance, exhibiting a degree of rage previously unseen. The patient may be diagnosed as schizophrenic, psychotic or manic-depressive.

The risk of misdiagnosis is increased because hypothyroidism inordinately impacts women - particularly women over the age of forty. As a result, the emotional difficulties are often attributed to the "natural" process of aging, possibly due to the empty-nest syndrome, the onset of menopause or other adjustments and changes in life. The elderly, especially those already living in a group home setting, face a doubly difficult task in receiving both the proper diagnosis and treatment for this condition.

That's the bad news. The good news is that diagnosis is actually quite straightforward. A simple blood test is all that's needed to identify a thyroid problem. The best news? When properly treated with a daily thyroid hormone you'll be your old self in no time flat.

Tim Anderson is a freelance writer who has a special interest in medical topics. Visit his blog at

What is Myxedema

What is Myxedema ?

The medical term myxedema is most commonly used to describe the physical characteristics of a person who has untreated hypothyroidism (an underactive thyroid). One typical feature of myxedema is generalized puffiness, especially noticeable in the face around the lips, nose and eyes. Other findings include:
  • Dry skin
  • Slow heart rate
  • Subnormal body temperature
  • Thick tongue
  • Low-pitched "husky" voice
  • Lethargy
  • Mental confusion (in advanced cases)
A diagnosis can be made with a simple blood test called a TSH (thyroid stimulating hormone). Treatment with thyroid medication should result in dramatic improvement of the symptoms and physical characteristics over time.

Monday, February 20, 2012

Myxedema Pictures

Myxedema Pictures
Myxedema Pictures: Patient before treatment (left) & after treatment (right)
Image source:

Myxedema Pictures
Myxedema Pictures
Image source:

Hypothyroidism (Myxedema) is a decreased activity of the thyroid gland which may affect all body functions. The rate of metabolism slows causing mental and physical sluggishness. The most severe form of hypothyroidism is myxedema, a medical emergency. Hypothyroidism can be caused by a problem with the thyroid itself (primary), or by the malfunction of the pituitary gland or hypothalamus (secondary).

Myxedema Coma

Myxedema coma is a rare syndrome that represents severe, long-standing hypothyroidism. It is a medical emergency, and the mortality rate can be as high as 60% even with early diagnosis and treatment. Most often elderly patients experience myxedema coma during winter season.

Common factors causing the coma include pulmonary infections, cerebrovascular accidents, congestive heart failure, trauma, surgery and not taking prescribed thyroid medications. Certain drugs used to treat anxiety and depression also can cause the disease in patients with hypothyroidism. The coma is often seen in hypothyroid patients who have been hospitalized for other medical problems.

Cardinal features of myxedema coma are reduced body temperature, respiratory depression and unconsciousness. Other clinical features include decreased heart rate, delayed reflexes, and dry, rough skin. Blood level of sodium decreases. The patient develops anemia. Hypothyroidism can be confirmed by measuring serum free thyroxine level and TSH (thyroid stimulating hormone) values.

Patients with this condition are in almost coma stage and they can not function normally. They need emergency care. Therapy includes supportive care, with ventilatory support, rewarming with blankets, and correction of low sodium levels. Throxine therapy is initiated in patients with the coma. Thyroxine is administered as an injection to these patients in potentially toxic doses.

If a person with hypothyroidism shows sudden changes in behaviour, shortness of breath or swelling of feet and hands, he/she should be directed to emergency care.

Early diagnosis and treatment of hypothyroidism, taking thyroid medication regularly and recognition of symptoms associated with it are some important ways by which myxedema coma can be prevented. If proper care is not taken, myxedema coma can even cause death.

Sunday, February 19, 2012

Myxedema Coma Symptoms

Myxedema Coma Symptoms:
Symptoms of hypothyroidism (Myxedema) may include the following:
  • Weakness
  • Confusion
  • Feeling cold
  • Low body temperature
  • Swelling of the body
  • Hypothermia
  • Hypoventilation
  • Decreased mental function
  • Fatigue
  • Activity intolerance
  • Hyporeflexia
  • Cardiac or respiratory failure
  • Difficulty breathing
People who have myxedema coma are in or near a coma and not able to function normally. They require emergency care.

Pretibial Myxedema Treatment

Pretibial Myxedema Treatment:

Usually Pretibial Myxedema is asymptomatic and can partially or completely resolve itself with time. Treatment is reserved for patients with cosmetic concerns, local discomfort, or functional impairment. As tobacco is associated with the autoimmune manifestations of Graves Disease, patients should be advised to stop smoking. Management of other risk factors, such as obesity, should be optimized. Although not yet proven, it has been suggested that the normalization of thyroid function has beneficial effects on Pretibial Myxedema.

The mainstay of treatment remains topical corticosteroids under an occlusive dressing (eg, 0.05% fluocinonide cream under a plastic film) every night or every other night for about 4 to 6 weeks. Frequency of application can gradually be reduced as the condition improves. In severe cases, a more potent topical steroid (eg, 0.05% clobetasol propionate cream) should be considered. In some cases, intralesional corticosteroid or hyaluronidase injections can be administered with caution. Systemic immunomodulation is rarely indicated in patients with localized Pretibial Myxedema. In those with associated Graves ophthalmopathy, however, systemic corticosteroids (eg, prednisone at 1–2 mg/kg daily) can prove beneficial. Case reports document mixed efficacy for octreotide, plasmapheresis, and intravenous immunoglobulin in the treatment of PM.

To minimize fluid accumulation in the lower extremities, compression bandages or stockings are valuable adjuvants for more severe forms of PM. Complete decompressive physiotherapy can help manage chronic lymphedema. Local excision of pseudotumorous lesions has been reported; however, surgical excision is not recommended, as PM is known to occur at sites of recent or previous trauma. Current therapies for PM are supportive at best; safer and more effective treatments are required.

Saturday, February 18, 2012

Pretibial Myxedema

Pretibial Myxedema, often referred to as localized myxedema or thyroid dermopathy, is an autoimmune manifestation of Graves disease. It affects approximately 4% of patients with Graves disease and has also been described in euthyroid and hypothyroid patients. The classic triad of ophthalmopathy, thyroid acropathy, and PM occurs in less than 1% of patients with Graves disease. With Graves Ophthalmopathy preceding PM in approximately 78% of cases, most patients with Pretibial Myxedema have underlying ocular disease.1 Pretibial myxedema has a gradual onset and typically develops 12 to 24 months after the diagnosis of thyrotoxicosis. It tends to affect older adults (peak incidence in the sixth decade of life); women are more frequently affected than men (female-to-male ratio 3.5:1).

There are 4 main clinical variants of Pretibial Myxedema: diffuse, non-pitting edema (43%); plaque (27%); nodular (18%); and elephantiasis (5%). The plaque and nodular forms usually occur on a background of nonpitting edema. The elephantiasic form is the most symptomatic and debilitating, consisting of nodular, polypoid, or fungating lesions with marked lymphedema. Lesions are commonly located in the pretibial regions and, less often, on the toes and feet. Involvement of the face, ears, chest, back, and upper extremities has rarely been described and has been associated with preceding trauma. The lesions can vary in colour and might exhibit a characteristic peau d’orange (orange peel) appearance and texture due to prominent hair follicles. Typically asymptomatic, they are rarely pruritic or painful. In severe cases associated with thyroid acropathy, bone pain can result from an underlying periosteal reaction. Hyperhidrosis, hypertrichosis, and entrapment neuropathies have also been reported.

All patients with active Pretibial Myxedema have antibodies against the thyroid-stimulating hormone receptor. Both humoral and cellular immune-mediated processes are involved in the stimulation of fibroblasts, resulting in the overproduction and accumulation of glycosaminoglycans (especially hyaluronic acid) in the dermis.

In most cases, diagnosis of Pretibial Myxedema is based on characteristic pretibial lesions, the presence of Graves Ophthalmopathy (especially exophthalmos), and a history of thyrotoxicosis. The diagnosis should be considered doubtful in the absence of Graves Ophthalmopathy. In select cases, a biopsy can be beneficial. Histopathologic findings include large amounts of glycosaminoglycans in the reticular dermis, fragmentation of collagen fibres, and marked edema. Stellate fibroblasts and a scant, perivascular lymphocytic infiltrate might also be observed.

Serologic evidence of thyroid autoimmunity could be required in some cases. Patients with active Pretibial Myxedema typically have high levels of serum thyroid-stimulating hormone receptor antibodies. Imaging studies (eg, bone radiography) can also help in diagnosing associated thyroid acropathy.

Differential diagnoses include simple edema resulting from chronic lymphatic obstruction or venous insufficiency, generalized myxedema, scleromyxedema, fibrosing dermopathy, diabetic dermopathy, cutaneous mucinosis, lichen amyloidosis, hypertrophic lichen planus, and chronic or lichenified dermatitis, such as lichen simplex chronicus.

Friday, February 17, 2012

Myxedema Definition

Myxedema Definition:

Myxedema It is a rare, complicated skin disease that is characterized by inflammation and thickening of the skin. It is known by various other names like “Advanced hypothyroidism” and “Graves’ Dermopathy”. The condition is also often called “Hypothyroidism” although it usually occurs in the advanced stages of that disease. In British English, the condition is referred to as “Myxoedema”. The condition is more common in women than men.

General information of Hypothyroidism (Myxedema):
  • Slowing of metabolic processes caused by hypofunction of the thyroid gland with decreased thyroid hormone secretion; causes myxedema in adults and cretinism in children (see Congenital Hypothyroidism, in Unit 5).
  • Occurs more often in women between ages 30-60.
  • Primary hypothyroidism: atrophy of the gland possibly caused by an autoimmune process.
  • Secondary hypothyroidism: caused by decreased stimulation from pituitary TSH.
  • Iatrogenic: surgical removal of the gland or overtreatment of hyperthyroidism with drugs or radioactive iodine.
  • In severe or untreated cases, myxedema coma may occur.
  • Characterized by intensification of signs and symptoms of hypothyroidism and neurologic impairment leading to coma.
  • Mortality rate high; prompt recognition and treatment essential.
  • Precipitating factors: failure to take prescribed medications; infection; trauma, exposure to cold; use of sedatives, narcotics, or anesthetics.