Clinical study of skin manifestations of hypothyroidism at a tertiary hospital in North Kerala

INTRODUCTION

Thyroid disorders affect multiple organs in the human body including the skin. Dermatological manifestations are common in both hyperthyroidism and hypothyroidism. Hypothyroidism is characterised by TSH levels <4.2 IU/ml, T3 <3.95 pmol/lt and T4 <12pmol/lt and the common skin findings include dry coarse skin, myxoedema, palmoplantar keratoderma, diffuse/localised hair loss, carotenemia, brittle hair and nails with reduced rate of growth and purpura.¹ The present study was conducted to understand the prevalence and pattern of various skin manifestations of hypothyroidism in this part of Kerala.

METHODS

A prospective descriptive clinical study of skin manifestations of hypothyroidism was done over a period of 1 year from September 2016 to August 2017 after getting institutional ethical clearance. The study sample consisted of 100 diagnosed cases of hypothyroidism who attended the Dermatology and General Medicine outpatient departments of Kannur Medical College, Anjarakandy.

Inclusion criteria

All patients with hypothyroidism willing for the study were included.

Exclusion criteria

Unwilling patients, patients who have undergone thyroid ablation or thyroidectomy, patients with other systemic illnesses like diabetes mellitus, hepatic, renal and cardiac disease, pregnant women and those already on thyroid hormone replacement therapy were excluded.

A detailed history was taken regarding the age of onset, site of involvement, type of skin lesions after taking written consent from the patients included in the study. A detailed systemic and cutaneous examination was done and the findings were recorded. Investigations done included complete blood count, urine examination, random blood sugar, liver and renal function tests, lipid profile, thyroid function test and skin biopsy.

RESULTS

Out of 100 patients 82 were females and 18 were males. The male to female ratio was 1:4.6. The age of patients ranges from 18 to 64 years with maximum number of patients in 21-40 years age group (Table 1). Out of the total study population, 68 patients had skin manifestations which included 56 females and 12 males. The common skin changes seen in the study were xerosis, myxoedema and palmoplantar keratoderma (Table 2). The main hair changes were hair loss and brittle lustreless hair (Table 3).

Nail involvement was seen in 24% of cases and the most common nail findings were brittle nails and onycholysis (Table 4). Alopecia areata, urticaria, vitiligo and melasma were seen in a significant number of cases (Table 5).

DISCUSSION

Thyroid disorders are commonly associated with various changes in the skin, hair and nails. In hypothyroidism, the hypometabolic state along with reflex peripheral vasoconstriction and reduced activity of sweat and sebaceous glands lead to cold pale coarse dry skin, palmoplantar keratoderma, brittle dry hair and nails.

In the present study hypothyroidism was more common in females with a male to female ratio of 1:4.6. This is similar to study by Srujana et al.²

The most common age group affected was 21-40 years. Srujana et al and Philip et al have noted similar findings.^2,3 Skin involvement was seen in 68% of cases. This is akin to findings by Haritha et al.⁴

The most common skin change noted was xerosis followed by myxoedema and keratoderma. Muhammed et al and Kumar et al have noted comparable findings.^5,6

Diffuse hair loss and brittle nails were the commonest hair and nail changes noted respectively. This is similar to findings by Philip et al and Kumar et al.^3,6

Associated conditions commonly seen were melasma, urticaria, alopecia areata and vitiligo. Similar observations were made by Haritha et al and Muhammed et al.^4,5 Purpura was noted in 3% of cases. Razi et al have recorded purpura in 8% of cases.⁷

The various signs and symptoms related to skin, hair and nails help in early diagnosis and treatment of hypothyroidism.

CONCLUSION

Skin, hair and nail problems are not rare in hypothyroidism. It is much more common in females and mainly affects the 21-40 years age group. The main skin changes are xerosis, keratoderma and myxoedema. Hair loss, dry brittle hair and nails and onycholysis are also commonly seen in hypothyroidism. A detailed knowledge of the various dermatological manifestations of hypothyroidism is must for an early diagnosis and will help to avoid complications in future.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

REFERENCES

1. 1. Dogra A, Dua A, Singh P. Thyroid and skin. Indian J Dermatol. 2006;51:96-9.
2. 2. Srujana B, Reddy BN, Prasad GK. Clinical spectrum of cutaneous manifestations of thyroid disorders in patients attending MediCiti Institute of Medical Sciences. Indian J Clin Experimental Dermatol. 2016;2(4):146-52.
3. 3. Nicely Philip, Banavasi S Girisha, Tonita M Noronha, Akshata C Alva, Carol Christy. Cutaneous manifestations of hashimoto’s thyroiditis: a cross-sectional study. Int J Contemporary Med Res. 2016;3(10):2910-4.
4. 4. Haritha S, Sampath K. Skin manifestations of hypothyroidism – A clinical study. IOSR-JDMS. 2013;7:58-60.
5. 5. Keen MA, Hassan I, Bhat MH. A Clinical Study of the Cutaneous Manifestations of Hypothyroidism in Kashmir Valley. Indian J Dermatol. 2013;58(4):326
6. 6. Kumar D, Aslami AN. Evaluation of general and cutaneous manifestations of hypothyroidism: a single center experience in Odisha. Int J Res Dermatol. 2016;2:64-8.
7. 7. Razi A, Golforoushan F, Nejad A, Goldust M. Evaluation of dermal symptoms in hypothyroidism and hyperthyroidism. Pak J Biol Sci. 2013;16:541-4.