Cutaneous Manifestations of Hypothyroidism amongst Gynecological consultations

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Hypothyroidsm may form a relatively diagnostic problem as its manifestations are usually subtle and can be easily overlooked. This was well apparent in the results of the survey carried out in County Durham, England, in which hypothyroidism was detected in 1.9% of women and was overt in 1.4%. The prevalence in men was less than 0.1 percent2. Moreover, recent surveys indicated hypothyroidism to be more prevalent in elderly population, reaching as high as 20%3. Another study among Framingham population showed that 5.9% of the women and 2.4% of men above the age of sixty had serum TSH levels more than 10mU/L4. In Ireland the prevalence of primary hypothyroidism has been stated as 8.6% in the women above the age of fifty years as compared to only 0.9% in younger females5. The incidence of congenital hypothyroidism was reported to be 1 in 2,640 in a study from India6. In iodine-replete areas, autoimmune thyroid disease and thyroablative therapy are the major reasons of hypothyroidism. Even in children and adolescents autoimmune thyroiditis is the commonest cause of non-endemic thyromegaly and acquired hypothyroidism7. However, worldwide, iodine deficiency is the leading cause of hypothyroidism8.

Many authors reports that hypothyroidsm have non specific clinical presentation and high degree of clinical suspicion is required before going for biochemical markers 11. The clinical manifestations of hypo-thyroidism are variable, depending upon its cause, duration, and severity. The spectrum extends from sub-clinical to overt hypothyroidism to myxedema coma. The characteristic pathological finding in a hypothyroid patient is the accumulation of hyaluronic acid and other glycosaminoglycans in the interstitial tissues.9

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Skin and cutaneous appendages are target organs for thyroid hormones. Thus, a variety of changes of skin, hair and nails occurs in association with thyroid diseases. Most of these cutaneous changes are unspecific, but in their entirety they may nonetheless be indicative of thyroid diseases 10. The diagnosis of thyroid disease can often first be identified by recognizing various cutaneous manifestations associated with an imbalance of circulating thyroid hormone.

In this study most of the cases coming with gynecologic problems particularly amenorrhea, dysparunia, PCO and PMS and Breast tenderness had also hypothyroidism. In the meantime they were found also to have evident skin manifestations mostly with urticaria and puffiness of hands and feet. They also showed higher frequency of yellow ivory skin and coarse rough dry skin along with other manifestations like alopecia and periorbital edema, vitiligo, brittle thick nails and eczema. These manifestations are mainly due to the accumulation of glycosaminoglycans in the interstitial space is responsible for coarse skin, puffy face and rough hair 12.

Our results are consistent with that of Jabbour who reported that in patients with hypothyroidism there is hair loss and the skin was cold and pale, with myxedema changes in the hands and periorbital region 13. Lenzoff and Sussman evaluated 624 cases with urticaria found 90 to have thyroid disease 14. Heymann has stated that the mechanism by which thyroid autoimmunity is associated with urticaria is unknown they have stated that there is a clustering of thyroid microsomal antibodies in patients with a positive autologus serum test 15. Thyroid dermopathy is said to be the most characteristic cutaneous sign of hypothyroidism which is characterized by generalized myxedema caused by deposition of dermal acid mucopolysaccharide especially hyluronic acid and chondritin sulphate 16.

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Although we excluded all pregnant ladies in our study while reviewing literature we noticed a study from Iran revealed that when thyroid status of mother was checked who have given birth to hypothyroid babies Subclinical hypothyroidism was diagnosed 17. This further strengthens our opinion that obstetricians and gynaecologists should be vigilant to look for any sign of thyroid disease in females.

This work stressed the strong association between cutaneous signs and symptoms with hypothyroidism especially among females with gynecologic problems. Gynecologists may commonly miss skin lesions while concentrating on the gynecological complaint only. Therefore, a high degree of suspicion must be kept in mind in patients presenting with such signs and symptoms to rule out an underlying thyroid disorder.


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About the Author: Tung Chi