This is an answer to the Case – Pretibial Hyperkeratosis, Fissuring, and Verrucous Nodules
A 51-year-old woman presented with weight loss (despite good appetite), palpitations, tremor, and heat intolerance. On examination, she had typical features of Graves’ disease, including a diffusely enlarged thyroid, periorbital edema, and proptosis, as well as mild thickening of the skin in the pretibial area.
The diagnosis was confirmed by the results of thyroid-function tests, which showed a thyroid-stimulating hormone level of less than 0.1 mU per milliliter (normal range, 0.5 to 5.15); a triiodothyronine level of 557 ng per deciliter (8.5 nmol per liter; normal range, 100 to 190 ng [1.5 to 2.9 nmol]); and a thyroxine level of 17.9 μg per deciliter (230.6 nmol per liter; normal range, 4.4 to 12.5 μg [56.6 to 160.9 nmol]).
She responded to antithyroid treatment with methimazole and propranolol and then had recurrent thyrotoxicosis when the medications were discontinued.
Two years later, she underwent a near-total thyroidectomy. Postoperatively, she had normal thyroid function with levothyroxine supplementation, but her pretibial skin changes worsened.
The dermopathy extended bilaterally from just below the knees to the feet. The skin was leathery in texture, with hyperkeratosis, fissuring, formation of verrucous nodules, and a change in pigment. A trial of therapy with topical steroids and compressive dressings was initiated without any noticeable improvement after one year.