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Current Insights On Treating Graves’ Dermopathy In The Foot

The authors present a case study of Graves’ dermopathy in the foot of a 54-year-old African-American female, who had a painful, disfiguring and growing mass on the dorsum of her right foot.

Graves’ dermopathy (also known as pretibial myxedema, thyroid dermopathy, Jadassohn-Dösseker disease or myxedema tuberosum) is an infiltrative dermopathy. It is a rare complication of Graves' disease with an incidence rate of about 1 to 5 percent in patients.1,2 Usually, when dermopathy is present, it is a late manifestation of the disease process and is preceded by other manifestations such as ophthalmopathy.

Graves’ dermopathy is classically described as having a peau d'orange (orange peel) appearance on the anterior aspect of the lower legs and this can spread to the dorsum of the feet. Mucin depositions are visible within the reticular layers of the skin upon microscopic examination.

We present a case study of Graves’ dermopathy in the foot of a 54-year-old African-American female, who presented to our podiatric clinic complaining of a painful, disfiguring and growing mass on the dorsum of her right foot. She noted the mass started a year ago and described it as slow growing. The patient had a past medical history significant for Graves’ disease (a greater than 10-year history), status post thyroidectomy, exophthalmos with lid lag, hypertension, gastroesophageal reflux disease and mild obstructive sleep apnea. The patient also smoked tobacco.

The patient had a five-year history of a bunionectomy to this same extremity with the most prominent portion of the soft tissue mass appearing to be continuous with the well-healed surgical scar. Upon further examination, the mass was firm, non-mobile and non-tender. The bilateral lower extremities were hyperpigmented with firm, indurated, non-pitting edema extending to the lower legs. No open lesions or ulcerations were present (see photos at top left).

What The Imaging And Pathology Report Revealed

Radiographs showed increased soft tissue densities over the dorsal portions of the first metatarsophalangeal joint and no cortical disruptions (see photos at right). Magnetic resonance imaging (MRI) with and without contrast suggested differentials such as keloid versus dermatofibrosarcoma protuberans and less likely differentials such as diffusely infiltrating synovial sarcoma and cutaneous lymphoma (mycosis fungoides). No bony involvement was evident. However, the mass appeared to communicate with the extensor hallucis longus tendon and tendon sheath.

We consulted with the reporting radiologist, bringing to light the patient’s medical history of Graves’ disease. His assessment changed to reflect that thyroid dermopathy was the most likely diagnosis and he recommended excisional biopsy.

We performed surgical excision of the larger lesion and took pathology sections. Pathology reported dermal mucinosis and confirmed this with the Alcian blue and elastic stains. The dermal mucinosis identified was consistent with the skin changes in pretibial myxedema in patients with Graves’ disease. No carcinogenic elements were present (see photos on the next page).

What You Should Know About Dermal Manifestations Of Thyroid Dermopathy

Pretibial myxedema, as its name implies, usually presents in the pretibial regions 99.4 percent of the time in patients with Graves’ disease.1,2 It is usually a late manifestation.

The general consensus is not to surgically excise these lesions unless they are painful because lesions can recur and be larger in size in comparison to the original. Due to the painful nature of this mass and the concerning differentials on MRI report, we performed an excisional biopsy.

Researchers have noted myxedema at the site of trauma or prior surgery.3-6 Dermopathy can develop in areas exposed to trauma and in scar tissues.9 A large amount of the elements visible on both MRI and microscopic examination confirmed this to be true for our patient as we identified large amounts of scar tissue.

Tobacco use is a major risk factor for the development and severity of extrathyroidal manifestations.7,8 Our patient had a longstanding history of tobacco use and she exhibited diffusely indurated skin changes bilaterally to her legs and feet.

It was interesting to note how drastically the differentials from the radiologist changed depending on the amount of clinical information he got. This points to the importance of the clinical practitioner to share as much information as possible with the radiology and pathology practitioners. Deciding how much of the soft tissue lesion to remove was based on the most painful area and an intraoperative decision as the lesion did not have a well-demarcated border and was localized deep to the surgical scar from a prior surgery.

Dr. Zinyemba is a third-year resident in the Podiatric Surgical Residency Program at Temple University Hospital in Philadelphia.

Dr. Pontious is a Professor and Chair of the Department of Podiatric Surgery at Temple University School of Podiatric Medicine in Philadelphia. She is a Fellow of the American College of Foot and Ankle Surgeons, and is a faculty member of the Podiatry Institute.

The authors thank Aneja Amandeep, MD, and Yuri Persidsky, MD, PhD, for the pathology slide pictures and captions.

References

1. Fatourechi V, Pajouhi M, Fransway AF. Dermopathy of Graves' disease. Medicine. 1994; 73(1):1-7.

2. Terry F, Davies P, Larsen PR. Thyrotoxicosis. In Larsen PR, Kronenberg H, Melmed S (eds.): Williams Textbook of Endocrinology, 10th Edition. WB Saunders, Philadelphia, 2003, pp. 379–401.

3. Wright AL, Buxton PK, Menzies D. Pretibial myxedema localized to scar tissue. Int J Dermatol. 1990; 29(1):54-55.

4. Missner SC, Ramsay EW, Houck HE, Kauffman CL. Graves’ disease presenting as localized myxedema in a thigh donor graft site. J Am Acad Dermatol. 1998; 39(5 Pt 2):846-849.


5. Pujol RM, Monmany J, Bague S, Alomar A. Graves’ disease presenting as localized myxoedematous infiltration in a smallpox vaccination scar. Clin Exp Dermatol. 2000;25(2):132-134.

6. Davies TF. Trauma and pressure explain the clinical presentation of the Graves’ disease triad. Thyroid. 2000; 10(8):629-630.

7. Cawood TJ, Moriarty P, O’Farrelly C, O’Shea D. Smoking and thyroid- associated ophthalmopathy: a novel explanation of the biological link. J Clin Endocrinol Metab. 2007; 92(1):59-64.

8. Wiersinga WM. Smoking and thyroid. Clin Endocrinol (Oxf). 2013; 79(2):145- 51.

9. Fatourechi V. Thyroid dermopathy and acropachy. Best Pract Res Clin Endocrinol Metab. 2012; 26(4):553-65.

10. Fatourechi V. Medical management of extrathyroidal manifestations of graves disease. Endocrine Practice. 2014; 20(12):1333-44.

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Priscilla Zinyemba, DPM, and Jane Pontious, DPM, FACFAS
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