A clinical study of the cutaneous manifestations of hypothyroidism in kashmir valley.

BACKGROUND: Thyroid disorders are known to involve all the organ systems of the body, the skin being no exception. The association of thyroid disorders with cutaneous manifestations is complex. Both hypothyroidism and hyperthyroidism are known to cause these changes. AIMS: The present study was designed to ascertain the varied cutaneous manifestations of hypothyroidism.
MATERIALS AND METHODS: This study was a hospital based clinical study conducted in collaboration with the Endocrinology Division (Department of Medicine) of SMHS Hospital (associated teaching hospital of Government Medical College Srinagar), over a period of one year, from May 2010 to May 2011. Four hundred and sixty consecutive diagnosed cases of hypothyroidism constituted the subject material for the study and were evaluated for the presence of any cutaneous manifestation.
RESULTS: In our study group of 460 patients, there were 416 females and 44 male patients. The predominant cutaneous symptom in our hypothyroid patients was dry coarse skin (65.22%), followed by hair loss (42.6%) and puffy edema (38.48%). The most common cutaneous sign observed in hypothyroid patients was xerosis (57.17%), followed by diffuse hair loss (46.09%), altered skin texture (31.74%), coarse scalp hair (29.35%) and puffy face (28.69%).
CONCLUSIONS: The interaction between thyroid gland and skin is of profound clinical importance in dermatological practice. So, dermatologists need to be cognizant of the ways in which these two organs interact.

What was known?

Both hypothyroidism and hyperthyroidism are known to have cutaneous manifestations. The cutaneous manifestations associated with hypothyroidism are protean as well as varied in nature.

Introduction

Thyroid hormones are instrumental in regulating the health and appearance of skin and when the thyroid gland becomes underactive or overactive, a variety of skin problems may result.[1] Cutaneous manifestations of hypothyroidism are protean in nature and affect all age groups. These dermatologic manifestations may occur secondary to the decreased thyroid hormone levels or due to the presence of thyroid autoantibodies that interact with skin components. Most of these cutaneous manifestations are nonspecific and many individuals without a definite thyroid problem may exhibit them. So, these do not allow diagnosis without the estimation of endocrine function.[2] Some dermatological findings and diseases may be the first symptoms of thyroid diseases.

Since there is a paucity of data regarding the cutaneous changes associated with hypothyroidism, the present study was designed to ascertain the varied cutaneous manifestations of hypothyroidism.

Materials and Methods

This study was a hospital based descriptive clinical study conducted in collaboration with the Endocrinology Division (Department of Medicine) of SMHS Hospital (associated teaching hospital of Government Medical College Srinagar).

Four hundred sixty consecutive diagnosed cases of hypothyroidism constituted the subject material for the study. These patients were evaluated for the presence of any cutaneous manifestation. There was no age limit for inclusion in the study. A detailed medical history pertaining to hypothyroidism was elicited in each case with particular reference to the cutaneous complaints including duration, history of evolution and progression. An informed consent was taken from each patient, after which a general physical examination, systemic examination and a detailed dermatological examination was carried out and the relevant details recorded and tabulated. Apart from routine laboratory investigations, thyroid function tests (TSH, T3 and T4) were also done by electro-chemiluminescence assay (ECLIA). Statistical analysis of the data was performed by appropriate statistical methods using Statistical Package for Social Sciences (SPSS Version 17) and inferences were drawn.

Results

A total of 460 hypothyroid patients were included in the study.

The age of patients ranged from 5 to 72 years, with a mean age of 38.42 (+11.02) years.

A female predominance was seen in our study with a male to female ratio of 1:9.5.

The medical complaints in the history in our study group are depicted in Table 1.

Table 1

Distribution of hypothyroid patients as per clinical history (N=460)

The most common cutaneous symptom in hypothyroid patients was dry coarse skin, noticed by 300 (65.22%) patients. This was followed by hair loss, reported by 196 (42.6%) patients. Puffy edema as a cutaneous symptom was reported by 177 (38.48%) patients, whereas pruritus was complained of by 79 (17.17%) patients. Decreased sweating and ivory yellow skin were noticed by 39 (8.48%) and 30 (6.52%) patients respectively. Purpura/ecchymosis was noticed by 19 (4.13%) patients, whereas brittle nails were reported by just 9 (1.96%) patients. Urticaria as a cutaneous complaint was reported by 60 (13.04%) patients. Most of these patients had more than one cutaneous symptom [Table 2]. No cutaneous symptoms were noticed by 35 (7.61%) patients.

Table 2

Cutaneous symptoms in hypothyroid patients (N=460)

The most common cutaneous sign observed was xerosis [Figure 1], seen in a total of 263 (57.17%) patients. This was followed by altered skin texture, which was seen in 146 (31.74%) patients. Puffy face [Figure 2] as a cutaneous sign was noticed in 132 (28.69%) of our patients. Keratoderma [Figure 3] and non-pitting edema were seen in 89 (19.35%) and 16 (3.48%) patients respectively. Carotenemia was noticed in 26 (5.65%) patients. The least common cutaneous sign in our patients was xanthelasma palpebrarum [Figure 4], which was noticed in 7 (1.52%) of our patients. No cutaneous signs were detected in 77 (16.74%) of our patients during examination. the cutaneous signs in our patients are tabulated in Table 3.

Figure 1

Xerosis in a patient of hypothyroidism

Figure 2

Puffy face in a hypothyroid female

Figure 3

Palmar keratoderma in a patient of hypothyroidism

Figure 4

Xanthelasma palpebrarum in a hypothyroid female

Table 3

Cutaneous signs in hypothyroid patients (N=460)

The predominant finding on examination of hair in our patients was diffuse hair loss [Figure 5], seen in 212 (46.09%) patients, followed by coarse scalp hair, seen in 135 (29.35%) patients. Madarosis, seen in just 9 (1.96%) patients was the least common hair change noticed in our patients. No hair changes were detected in 193 (41.96%) patients. Hair changes are depicted in Table 4.

Figure 5

Diffuse hair loss in a female with hypothyroidism

Table 4

Hair changes in hypothyroid patients (N=460)

The commonest nail change in hypothyroid patients was brittle nails (4.35%), followed by slow nail growth, noticed in 3 (0.65%) patients.

The other associated cutaneous diseases which we noticed in the patients are depicted in Table 5.

Table 5

Associated cutaneous diseases in hypothyroid patients (N=460)

Mean and median values of TSH, T3 and T4 in our patients are shown in Table 6.

Table 6

Thyroid function status

Discussion

The skin in hypothyroidism becomes cool, xerotic, pale and is covered with fine scales resembling ichthyosis.[3] Hypohidrosis, possibly accompanied by diminished epidermal sterol biosynthesis, may lead to acquired palmoplantar keratoderma.[456] A yellowish hue may be imparted to the skin, particularly on the palms, soles, and nasolabial folds, as a result of carotenemia observed in hypothyroidism.[7]

Hair changes manifest as dry, coarse, brittle hair, with a tendency to fall out, resulting in diffuse, partial alopecia.[8] The eyebrows frequently disappear with loss usually originating laterally (madarosis).[910]

Nails are thin, striated, brittle and grow slowly. Onycholysis has also been reported.[3]

Hypothyroidism may be associated with a number of different cutaneous and/or systemic diseases. The cutaneous diseases associated with hypothyroidism include alopecia areata,[1112] chronic urticaria,[131415] vitiligo,[1617] and scleroderma.[18]

In our study group of 460 patients, there were 416 (90.43%) females and just 44 (9.57%) males, which corresponds to the study conducted by Indra et al.,[19] who observed 87% female patients in their study. This observation of female preponderance may be due to an increased association of autoimmune disorders in females, autoimmunity being an important cause of hypothyroidism.

The predominant cutaneous symptom in our patients was dry skin (65.22%), followed by hair loss (42.6%) and puffy edema (38.48%). Pruritus was complained by 17.17% patients, whereas decreased sweating by 8.48% of patients. Similar observations were made by Jabbour et al.,[20] and Hueston, et al.,[21] in their studies. Urticaria was reported as a cutaneous complaint by 13.04% of patients, quite comparable to the study conducted in by Dogra et al.,[22] who found urticaria as a cutaneous complaint in 15% of their patients. Ivory yellow skin was a cutaneous complaint in 6.52% cases, which is in concordance with the result of the study by Rai et al.,[23] who reported it to be present in 5.12% of their cases. Purpura was reported by 4.13% of our patients, similar to the results of the study by Christianson HB,[24] who reported purpura to be present in 4.05% of hypothyroid patients. The least common cutaneous symptom was brittle nails, reported by 1.96% of cases.

We observed that the most common cutaneous sign was xerosis (57.17%), followed by altered skin texture (31.74%). Our results were quite similar to that mentioned by Dogra et al.,[22] in their study, in which xerosis was found to be present in 59.37% of their patients. Puffiness of face was noticed in 28.69% of patients in our study as against 63.3% as reported by Khurram et al.[25] Keratoderma and carotenemia were seen in 19.35% and 5.65% of patients respectively carotenemia was much less than that reported by Rai, et al.,[23] in their study. They reported keratoderma and carotenemia in 72% and 5% of their patients. In our study, xanthelasma palpebrarum was the least common cutaneous sign, seen in 1.52% patients, whereas in a study by Dogra, et al.,[22] it was noticed in 3.1% of their patients.

The predominant finding on examination of hair was diffuse hair loss, seen in 46.09% of cases. This finding shared similarity with the study conducted by Dogra, et al.,[22] in which diffuse hair loss was noted in 40.62% of patients. Coarse hair was found in 29.35% of patients in our study. This observation was in contrast to the results of the study conducted by Hueston WJ,[21] in which coarse hair was seen in 76% of cases.

The most common nail change in our patients was brittle nails, seen in 4.35% of cases, comparable to the study by Dogra et al., who noticed nail changes in 6% of their patients.

In our study, we noticed a variety of associated cutaneous diseases in our patients. Vitiligo was seen in 7 of our patients. Studies by Moradi et al.,[26] and Gopal et al.,[27] have found an association between hypothyroidism and vitiligo.

Melasma was noticed as an associated cutaneous disease in 6 of our patients. The association has been well documented by Lufti, et al.,[28] in their study.

Acanthosis nigricans was noticed in 4 patients of our patients. Kuroki, et al.,[29] have found an association between hypothyroidism and acanthosis nigricans. Systemic sclerosis was seen in 2 of our patients. De Keyser, et al.,[30] reported an association between systemic sclerosis and hypothyroidism, thus corroborating our finding.

We found one patient with discoid lupus lupus erythematosus. Callen JP[31] reported discoid lupus lupus erythematosus in a patient with autoimmune thyroiditis, thus corroborating our observation.

Alopecia areata was seen in 2 of our patients. It is a known association which has been established in various studies, such as those conducted by Tosti, et al.,[11] and Thomas, et al.[32]

Other associated diseases which we noticed included granuloma annulare, Becker's nevus, polymorphic light eruption, actinic keratosis, ephelides, seborrhoeic keratosis, lichen planus, herpes simplex, acrochordons, psoriasis, acne vulgaris, seborrhoeic dermatitis. We believe that these findings in our patients were coincidental.

Conclusion

We conclude that the interrelationship between thyroid gland and skin is dynamic and complex. So, dermatologists need to be cognizant of the ways in which these two organs interact. Various symptoms and signs related to skin, hair and nails go unrecognized and most of the times are not investigated properly. So, patients presenting with such signs and symptoms should be investigated properly to rule out any underlying thyroid disorder.

What is new?

Patients presenting with various signs and symptoms related to skin, hair and nails should be investigated promptly for any underlying thyroid dysfunction.