Response of a Patient with Severe Thyroid Dermopathy to Combined Multipoint Subcutaneous Injection of Glucocorticoids and Local Excision

Dear Editor:

A 56-year-old man, with a 10-year history of exophthalmos and five-year history of thyroid dermopathy, was admitted to the endocrinology department. He was a farmer working in his hometown. Ten years earlier, he presented with a small goiter, mild palpitations, and exophthalmos (20 mm), and he was diagnosed with Graves' disease and thyroid-associated opthalmopathy in a local hospital. He was treated with propylthiouracil. He then gradually developed diplopia. After a five-year period of antithyroid medication, he received radioactive iodine treatment. Subsequently, his exophthalmos became worse (23 mm), and he developed mild photophobia and conjunctival injection. His thyroid function tests revealed that he had developed hypothyroidism, and the patient was started on levothyroxine (125 μg per day) and prednisone (dose not known). Unexpectedly, he subsequently developed multiple ridgy verruca-like plaques in some regions of his body. A skin biopsy showed abundant deposition of glycosaminoglycans in these lesions, and a diagnosis of thyroid dermopathy was established. During the past three years, after withdrawal of prednisone treatment, his dermopathy improved to some extent, but the photophobia and diplopia of both eyes persisted.

After admission to our department, physical examination revealed ridgy verruca-like plaques on his feet, the dorsa of the hands, and the upper back (Fig. 1: before treatment). Acropachy of both hands was also present. Apparent exophthalmos with retraction of the upper eyelids but with normal closing of the eyelids, as well as conjunctival injection, were noted. The vision of his left and right eyes was 0.6 and 0.8, respectively. Ocular movements were normal. He was treated with 125 μg of levothyroxine and 30 mg of prednisone daily for one week, and the photophobia improved to some extent. During the next five months, the levothyroxine dose was gradually reduced to 50 μg, and he remained euthyroid. The prednisone was reduced to 10 mg daily. The patient underwent monthly local excisions of the plaques on the right shoulder on two occasions, and he then underwent five monthly excisions of the lesions on his feet. Then he received monthly injections of a solution of 40 mg/mL of triamcinolone and 9 mL of normal saline on a monthly basis for three months into the dorsa of the hands, the left shoulder, and the feet. Each injection point was 0.5–1 cm apart, and there were about 20–30 injection sites in each region. The diameter of the needle was 0.45 mm. The response in the injected sites was favorable (Fig. 1: after treatment). Although the patient was scheduled to undergo further glucocorticoid injections, he left and returned to his hometown.

OPEN IN VIEWER

FIG. 1.

The patient presented with exophthalmos and skin appearance changes. Dermopathy lesions of the right shoulder recurred after local excision. The left shoulder and the dorsa of both hands were a bit improved after glucocorticoid injections. The feet presented the most favorable effect by combining injection of glucocorticoids and local excisions.

This patient presented with typical thyroid dermopathy, exophthalmos, and acropachy associated with Graves' disease. His dermopathy affected regions of the skin that are not usually involved. Thyroid dermopathy typically develops at sites exposed to pressure or trauma on a background of subclinical, systemic inflammation (1). Scar tissues, composed of abundant fibroblasts, are susceptible regions as well (2).

The patient presented here showed a demarcation of his dermopathy at the top of his shoes, as previous cases (1). In addition, he reported that his dermopathy was more evident on the right shoulder than on the left, possibly due to carrying a heavy vegetable basket on the right side during farm work. Local excision can be a traumatic factor, which can contribute to the recurrence of dermopathy lesions. The reason for his dermopathy on the dorsa of the hands remains unclear.

As reported previously (3), multipoint subcutaneous injection of glucocorticoids can be effective, and this patient showed a good response. Multipoint glucocorticoid injections can shorten the duration of the dermopathy and provide satisfactory results. Injections performed with mesotherapy needles of 4–13 mm and delivering the medication into subcutaneous tissue has shown good long-term results (4). Current therapies vary depending on the character and severity of the patients, and there is a lack of uniform and normative standard treatments. The management of thyroid dermopathy remains a therapeutic challenge, but as illustrated here, it can respond favorably to local glucocorticoid injections.