Long Case – Pretibial myxedema

Case Scenario:
A 55-year-old female is referred to dermatology due to a lesions over both shins. On examination
symmetrical erythematous lesions are found with an orange peel texture.
What is the likely diagnosis and discuss your management.

Most likely diagnosis:

Pretibial Myxedema/ Thyroid dermopathy.
 Based on the characteristic appearance and location of the lesions, pretibial myxedema is
the most likely diagnosis. Pretibial myxedema is most commonly presented on the shins
or dorsum of the foot. [1]
 Pretibial myxedema is not always associated with Graves’ disease and there was no
mention of hyperthyroid signs and symptoms. [1] However it can present before, during or
after thyrotoxic state. [2],[4]
 Pretibial myxedema is more common in women than men and typically presents in the
50s and 60s which corresponds to the gender and age of the patient. [2]

Differential Diagnoses:
 Erythema nodosum [3]
 It is a delayed hypersensitivity reaction triggered by a number of different things
which include but not limited to: infection, drugs, pregnancy, malignancy, and
inflammatory conditions. [6],[3]
 The most common site is the shins and presents as its name suggests, i.e.
erythematous nodules which are tender. [6] The patient’s lesions were not tender
and erythema nodosum does not have an orange peel texture.
 It is more common in women between the ages of 20 to 40. [6]
 Insect bites [2]
 Insect bites can have the same presentation as the patient did with the exception of
the orange peel texture. [9]
 Insect bites can occur to anyone.
  Stasis dermatitis [1]
 It is erythematous, scaling, and eczematous patches on the shin and ankles but it
does not have an orange peel texture. [5]
 It is due to venous insufficiency. [5]
 It typically occurs in middle aged and the elderly. [5]
 Secondary lymphedema [2], [7]
 It has various etiologies. [7],[8]
 However, it typically occurs unilaterally. The patient’s lesions are bilateral. [7],[8]

Management:
- History taking:
o I would ask the patient of previous abnormal thyroid function whether it be
Graves’ disease, Hashimoto’s disease or primary hypothyroidism since pretibial
myxedema can present in either. However, it is more commonly presented in
Graves’ disease. Pretibial myxedema can present after thyrotoxic state, i.e. after
diagnosis. [2],[4]
- Physical Examination
o I would perform a thyroid examination whereby checking if there is non-pitting
edema which is characteristic of pretibial myxedema.
- Investigations:
o If there is no history of abnormal thyroid state or history of autoimmune disease a
punch biopsy should be done. [1]
o Thyroid function test. It is unlikely that the results would be abnormal due to the
lack of signs and symptoms for hypothyroidism or hyperthyroidism. However,
this particular presentation of pretibial myxedema could be before or after
diagnosis of Graves’ disease or another thyroid disease.
- Treatment:
o I would advise the patient to reduce risk factors for thyroid disease. These include
no use of tobacco, to obtain and maintain a healthy BMI and to ensure that thyroid
function is normal. In order to ensure thyroid function is normal, thyroid function
 tests were recommended in investigations such that if results indicated
hypothyroidism or hyperthyroidism, it would be treated respectively. [1]
o Additionally, alongside the following pharmacological treatment, compression
stockings that can provide 20-40 mm Hg of pressure can also be used. [1],[2]
o I would prescribe a moderate potency topical steroid, desonide, to be applied each
night. After application of the topical steroid, the area should be wrapped by an
occlusive dressing. I would advise and show my patient how to do the dressing on
their own. [1],[2]
o If there is no improvement after 4 to 12 weeks of the use of the topical treatment,
I would then advise my patient on corticosteroid injections (triamcinolone
acetonide acetate) which would be injected into the lesions. Injections would
occur weekly until the lesions disappear. The dose for each weekly session would
not be more than 100 mg but the dose would be calculated for each lesion i.e. 8mg
per 3cm2. [1], [2]

References:
[1] Davies TF. Pretibial myxedema (thyroid dermopathy) in autoimmune thyroid disease
[Internet]. Ross DS, Mulder JE, editors. Uptodate; 2019 [cited 2020Oct18]. Available from:
https://www-uptodate-com.ezproxy.sastudents.uwi.tt/contents/pretibial-myxedema-thyroid-
dermopathy-in-autoimmune-thyroid-disease?search=pretibial
%20myxedema&source=search_result&selectedTitle=1~20&usage_type=default&display_rank
=1#H4

[2] Gill RS, Elston DM. Pretibial Myxedema [Internet]. Butler DF, Mowad CM, editors.
Medscape; 2020 [cited 2020Oct18]. Available from:
https://emedicine.medscape.com/article/1103765-overview

[3] Shin lesions - Training resources [Internet]. Google Sites. [cited 2020Oct18]. Available from:
https://sites.google.com/site/medicalwebsitesforgps/dermatology/shin-lesions

[4] Gardner DK. Pretibial myxoedema [Internet]. Morrison C, Oakley DA, editors. Pretibial
myxoedema | DermNet NZ. 2014 [cited 2020Oct18]. Available from:
https://www.dermnetnz.org/topics/pretibial-myxoedema/

[5] Flugman SL, Clark RA. Stasis Dermatitis [Internet]. Elston DM, editor. Medscape. 2020
[cited 2020Oct18]. Available from: https://emedicine.medscape.com/article/1084813-
overview#a4
[6] Kroshinsky D. Erythema nodosum [Internet]. Callen J, Ofori AO, Romain PL, editors.
Uptodate. 2020 [cited 2020Oct18]. Available from: https://www-uptodate-
com.ezproxy.sastudents.uwi.tt/contents/erythema-nodosum?search=erythema
%20nodosum&source=search_result&selectedTitle=1~149&usage_type=default&display_rank=
1

[7] Riches P, Sampson S. Lymphedema: Symptoms, treatments, and causes [Internet]. Medical
News Today. MediLexicon International; 2019 [cited 2020Oct18]. Available from:
https://www.medicalnewstoday.com/articles/180919

[8] Mehrara B. Clinical features and diagnosis of peripheral lymphedema [Internet]. Collins KA,
editor. Uptodate. 2019 [cited 2020Oct18]. Available from: https://www-uptodate-
com.ezproxy.sastudents.uwi.tt/contents/clinical-features-and-diagnosis-of-peripheral-
lymphedema?search=lymphedema&topicRef=17013&source=see_link#H33

[9] Boyd (Bo) D Burns DO. Insect Bites [Internet]. Background, Pathophysiology,
Epidemiology. Medscape; 2020 [cited 2020Oct18]. Available from:
https://emedicine.medscape.com/article/769067-overview