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Cutaneous Manifestations of Endocrine Disorders

A Guide for Dermatologists

American Journal of Clinical Dermatology volume 4, pages 315–331 (2003)Cite this article

Abstract

Thyrotoxicosis may lead to multiple cutaneous manifestations, including hair loss, pretibial myxedema, onycholysis and acropachy. In patients with hypothyroidism, there is hair loss, the skin is cold and pale, with myxedematous changes, mainly in the hands and in the periorbital region.

The striking features of Cushing syndrome are centripetal obesity, moon facies, buffalo hump, supraclavicular fat pads, and abdominal striae. In Addison disease, the skin is hyperpigmented, mostly on the face, neck and back of the hands.

Virtually all patients with acromegaly have acral and soft tissue overgrowth, with characteristic findings, like macrognathia and enlarged hands and feet. The skin is thickened, and facial features are coarser.

Conditions leading to hyperandrogenism in females present as acne, hirsutism and signs of virilization (temporal balding, clitoromegaly).

A prominent feature of hypopituitarism is a pallor of the skin with a yellowish tinge. The skin is also thinner, resulting in fine wrinkling around the eyes and mouth, making the patient look older.

Primary hyperparathyroidism is rarely associated with pruritus and chronic urticaria. In hypoparathyroidism, the skin is dry, scaly and puffy. Nails become brittle and hair is coarse and sparse. Pseudohypoparathyroidism may have a special somatic phenotype known as Albright osteodystrophy. This consists of short stature, short neck, brachydactyly and subcutaneous calcifications.

Some of the cutaneous manifestations of diabetes mellitus include necrobiosis lipoidica diabeticorum, diabetic dermopathy, scleredema adultorum and acanthosis nigricans.

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References

  1. Brownlie BE, Wells JE. The epidemiology of thyrotoxicosis in New Zealand: incidence and geographical distribution in North Canterbury, 1983–1985. Clin Endocrinol 1990; 33 (2): 249–259

    Article  CAS  Google Scholar 

  2. Reinwein D, Benker G, Konig MP, et al. The different types of hyperthyroidism in Europe: results of a prospective study of 924 patients. J Endocrinol Invest 1988; 11 (3): 193–200

    PubMed  CAS  Google Scholar 

  3. Williams I, Ankrett VO, Lazarus JH, et al. Aetiology of hyperthyroidism in Canada and Wales. J Epidemiol Community Health 1983; 37 (3): 245–248

    Article  PubMed  CAS  Google Scholar 

  4. Dabon-Almirante CLM, Surks MI. Clinical and laboratory diagnosis of thyrotoxicosis. Endocrinol Metab Clin North Am 1998; 27 (1): 25–35

    Article  PubMed  CAS  Google Scholar 

  5. Mullin GE, Eastern JS. Cutaneous signs of thyroid disease. Am Fam Physician 1986; 34 (4): 93–98

    PubMed  CAS  Google Scholar 

  6. Holt PJA, Lazarus J, Marks R. The epidermis in thyroid disease. Br J Dermatol 1976; 95: 513–518

    Article  PubMed  CAS  Google Scholar 

  7. Rosen T, Kleman GA. Thyroid and the skin. In: Callen JP, Jorizzo JL Greer KE, et al., editors. Dermatologic signs of internal disease. 2nd ed. Philadelphia: WB Saunders, 1995: 189

    Google Scholar 

  8. Heymann WR. Cutaneous manifestations of thyroid disease. J Am Acad Dermatol 1992; 26: 885–902

    Article  PubMed  CAS  Google Scholar 

  9. Freinkel RK. Cutaneous manifestations of endocrine diseases. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al., editors. Dermatology in general medicine. 4th ed. New York: McGraw-Hill, 1993: 2113–2131

    Google Scholar 

  10. Rook A. Endocrine influences on hair growth. BMJ 1965; 1: 609–614

    Article  PubMed  CAS  Google Scholar 

  11. Rook A, Dawber R. Diseases of the hair and scalp. 2nd ed. Oxford: Blackwell Scientific Publications, 1991: 147

    Google Scholar 

  12. Norton LA. Disorders of the nails. In: Moschella SL, Hurley HJ, editors. Dermatology. 3rd ed. Philadelphia: WB Saunders, 1992: 1574

  13. Locke W. Unusual manifestations of Graves’ disease. Med Clin North Am 1967; 51 (4): 915–924

    PubMed  CAS  Google Scholar 

  14. Mullin GE, Eastern JS. Cutaneous consequences of accelerated thyroid function. Cutis 1986; 37: 109–114

    PubMed  CAS  Google Scholar 

  15. Davis PJ, Davis FB. Hyperthyroidism in patients over the age of 60 years. Medicine 1974; 53 (3): 161–181

    Article  PubMed  CAS  Google Scholar 

  16. Heymann WR. The skin in thyrotoxicosis. In: Braverman LE, Utiger RD, editors. The thyroid. 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2000: 593–595

    Google Scholar 

  17. Ortonne J-P, Mosher DB, Fitzpatrick TB. Vitiligo and other hypomelanoses of hair and skin. New York: Plenum, 1983: 182

    Book  Google Scholar 

  18. Cunliffe WJ, Hall R, Newell DJ, et al. Vitiligo, thyroid disease and autoimmunity. Br J Dermatol 1968; 80: 135–139

    Article  PubMed  CAS  Google Scholar 

  19. Shong YK, Kim JA. Vitiligo in autoimmune thyroid disease. Thyroidology 1991; 3: 89–91

    PubMed  CAS  Google Scholar 

  20. Kantor GR, Bernhard JD. Investigation of the pruritic patient in daily practice. Semin Dermatol 1995; 14: 290–296

    Article  PubMed  CAS  Google Scholar 

  21. Readett MD. Constitutional eczema and thyroid disease. Br J Dermatol 1964; 76: 126–139

    Article  PubMed  CAS  Google Scholar 

  22. Collet E, Petit J-M, LaCroix M, et al. Chronic urticaria and thyroid auto-immunity. Ann Dermatol Venereol 1995; 122 (6–7): 413–416

    PubMed  CAS  Google Scholar 

  23. Pegum JS, Grice K. Unusual skin eruptions with eosinophilia associated with hyperthyroidism. Br J Dermatol 1973; 88 (3): 295–301

    Article  PubMed  CAS  Google Scholar 

  24. Thomson JA. Xanthelasma associated with thyrotoxicosis. J Clin Endocrinol Metab 1965 (Pt 1); 25: 758–760

    Article  Google Scholar 

  25. Fatourechi V, Pajouhi M, Fransway AF. Dermopathy of Graves’ disease (pretibial myxedema): review of 150 cases. Medicine 1994; 73 (1): 1–7

    Article  PubMed  CAS  Google Scholar 

  26. Horiuchi Y. Pretibial myxedema associated with chronic thyroiditis [letter]. Arch Dermatol 1985; 121 (4): 451

    Article  PubMed  CAS  Google Scholar 

  27. McDougall IR. Graves’ disease: current concepts. Med Clin North Am 1991; 75: 79–95

    PubMed  CAS  Google Scholar 

  28. Moule B, Grant MC, Boyle IT, et al. Thyroid acropachy. Clin Radiol 1970; 21: 329–333

    Article  PubMed  CAS  Google Scholar 

  29. Solanki SV, Shah SS, Kothari UR. Thyroid acropachy. Indian J Med Sci 1973; 27: 708–710

    PubMed  CAS  Google Scholar 

  30. Ross DS. Serum thyroid-stimulating hormone measurement for assessment of thyroid function and disease. Endocrinol Metab Clin North Am 2001; 30 (2): 245–264

    Article  PubMed  CAS  Google Scholar 

  31. Ladenson PW. Diagnosis of thyrotoxicosis. In: Braverman LE, Utiger RD, editors. Werner and Ingbar’s the thyroid. 7th ed. Philadelphia: Lippincott-Raven, 1996: 708–712

    Google Scholar 

  32. Kaplan MM, Meier DA, Dworkin HJ. Treatment of hyperthyroidism with radioac tive iodine. Endocrinol Metab Clin North Am 1998; 27 (1): 205–223

    Article  PubMed  CAS  Google Scholar 

  33. Cooper DS. Antithyroid drugs for the treatment of hyperthyroidism caused by Graves’ disease. Endocrinol Metab Clin North Am 1998; 27 (1): 225–247

    Article  PubMed  CAS  Google Scholar 

  34. Ross DS. Syndromes of thyrotoxicosis with low radioactive iodine uptake. Endocrinol Metab Clin North Am 1998; 27 (1): 169–185

    Article  PubMed  CAS  Google Scholar 

  35. Braverman LE, Utiger RD. Introduction to hypothyroidism. In: Braverman LE, Utiger RD, editors. Werner and Ingbar’s the thyroid. 7th ed. Philadelphia: Lippincott-Raven, 1996: 736–737

    Google Scholar 

  36. Larsen PR, Davies TF, Hay ID. The thyroid gland. In: Wilson JD, Foster DW, Kronenberg HM, et al, editors. Williams textbook of endocrinology. 9th ed. Philadelphia: WB Saunders, 1998: 460–466

    Google Scholar 

  37. Bernhard JD, Freedberg IM, Vogel LN. The skin in hypothyroidism. In: Braverman LE, Utiger RD, editors. Werner and Ingbar’s the thyroid. 7th ed. Philadelphia: Lippincott-Raven, 1996: 792–795

    Google Scholar 

  38. Wayne EJ. Clinical and metabolic studies in thyroid disease. BMJ 1960; 1: 78–90

    Article  PubMed  CAS  Google Scholar 

  39. Diven DG, Gwinup G, Newton RC. The thyroid. Dermatol Clin 1989; 7: 547–558

    PubMed  CAS  Google Scholar 

  40. Al-Jubouri MA, Coombes EJ, Young RM, et al. Xanthoderma: an unusual presentation of hypothyroidism. J Clin Pathol 1994; 47 (9): 850–851

    Article  PubMed  CAS  Google Scholar 

  41. Orteu CH, Rustin MH. 20 thickened, fragile nails. Lancet 1996; 347 (9002): 662

    Article  PubMed  CAS  Google Scholar 

  42. Tosti A, Baran R, Dawber RPR. The nail in systemic diseases and drug-induced changes. In: Baran R, Dawber RPR, editors. Diseases of the nails and their management. 2nd ed. Oxford: Blackwell Scientific Publications, 1994: 175

    Google Scholar 

  43. Cunningham MJ, Zone JJ. Thyroid abnormalities in dermatitis herpetiformis: prevalence of clinical thyroid disease and thyroid autoantibodies. Ann Intern Med 1985; 102 (2): 194–196

    PubMed  CAS  Google Scholar 

  44. Stockigt JR. Free thyroid hormone:treasurement. Endocrinol Metab Clin North Am 2001; 30 (2): 265–289

    Article  PubMed  CAS  Google Scholar 

  45. Ladenson PW. Diagnosis of hypothyroidism. In: Braverman LE, Utiger RD, editors. Werner and Ingbar’s the thyroid. 7th ed. Philadelphia: LippincottRaven, 1996: 878–882

    Google Scholar 

  46. Brent GA, Larsen PRo Treatment of hypothyroidism. In: Braverman LE, Utiger RD, editors. Werner and Ingbar’s the thyroid. 8th ed. Philadelphia: LippincottRaven, 2000: 853–858

    Google Scholar 

  47. Niepomniszcze H, Huaier AR. Skin disorders and thyroid diseases. J Endocrinol Invest 2001; 24: 628–638

    PubMed  CAS  Google Scholar 

  48. Lutfi RJ, Fridmanis M, Misiunas AL, et al. Association of melasma with thyroid autoimmunity and other thyroidal abnormalities and their relationship to the origin of the melasma. J Clin Endocrinol Metab 1985; 61 (1): 28–31

    Article  PubMed  CAS  Google Scholar 

  49. Hegedus L, Heidenheim M, Gervil M, et al. High frequency of thyroid dysfunction in patients with vitiligo. Acta Derm Venereol 1994; 74: 120–123

    PubMed  CAS  Google Scholar 

  50. McDonagh AJ, Messenger AG. The pathogenesis of alopecia areata. Dermatol Clin 1996; 14: 661–670

    Article  PubMed  CAS  Google Scholar 

  51. Leznoff A, Sussman GL. Syndrome of idiopathic chronic urticaria and angioedema with thyroid autoimmunity: a study of 90 patients. J Anergy Clin Immunol 1989; 84 (1): 66–71

    Article  CAS  Google Scholar 

  52. Rurnbyrt JS, Katz JL, Schocket AL. Resolution of chronic urticaria in patients with thyroid autoimmunity. J Anergy Clin Immunol 1995; 96 (6): 901–905

    Article  Google Scholar 

  53. Orgiazzi J. Anti-TSH receptor antibodies in clinical practice. Endocrinol Metab Clin North Am 2000; 29 (2): 339–355

    Article  PubMed  CAS  Google Scholar 

  54. Findling JW, Aron DC, Tyrrell JB. Glucocrticoids and adrenal androgens. In: Greenspan FS, Strewler GJ, editors. Basic & clinical endocrinology. 5th ed. Connecticut: Appleton & Lange, 1997: 343–354

    Google Scholar 

  55. Findling JW, RaffH. Diagnosis and differential diagnosis of Cushing’s syndrome. Endocrinol Metab Clin North Am 2001; 30 (3): 729–747

    Article  PubMed  CAS  Google Scholar 

  56. Yanovski JA, Cutler GB. Glucocorticoid action and the clinical features of Cushing’s syndrome. Endocrinol Metab Clin North Am 1994; 23 (3): 487–509

    PubMed  CAS  Google Scholar 

  57. Panzer SW, Patrinely JR, Wilson HK. Exophthalmos and iatrogenic Cushing’s syndrome. Ophthal Plast Reconstr Surg 1994; 10 (4): 278–282

    Article  PubMed  CAS  Google Scholar 

  58. Fisher B, Maibach HF. The effect of corticosteroids on human epidermal mitotic activity. Arch Dermatol 1971; 103: 39–43

    Article  PubMed  CAS  Google Scholar 

  59. Rokowski K, Sheehy J, Cutroneo KR. Glucocorticoid-mediated selective reduction of functioning collagen messenger ribonucleic acid. Arch Biochem Biophys 1981; 210: 74–77

    Article  PubMed  CAS  Google Scholar 

  60. Ferguson JK, Donald RA, Wetson TS, et al. Skin thickness in patients with acromegaly and Cushing’s syndrome and response to treatment. Clin Endocrinol 1983; 18 (4): 347–353

    Article  CAS  Google Scholar 

  61. Orth DN, Kovacs WJ. The adrenal cortex. In: Wilson JD, Foster DW, Kronenberg HM, et al, editors. Williams textbook of endocrinology. 9th ed. Philadelphia: WB Saunders, 1998: 565–569

    Google Scholar 

  62. Matsuoka LY, Gavin JR, Goldman l Spectrum of endocrine abnormalities associated with acanthosis nigricans. Am J Med 1987; 83: 719–725

    Article  PubMed  CAS  Google Scholar 

  63. Winkelmann RK, Scheen RS, Underhal LO. Acanthosis nigricans and endocrine disease. JAMA 1960; 174 (9): 1145–1152

    Article  PubMed  CAS  Google Scholar 

  64. Findling JW, Raff H. Newer diagnostic techniques and problems in Cushing’s disease. Endocrinol Metab Clin North Am 1999; 28 (1): 191–210

    Article  PubMed  CAS  Google Scholar 

  65. Meier CA, Biller BMK. Clinical and biochemical evaluation of Cushing’s syndrome. Endocrinol Metab Clin North Am 1997; 26 (4): 741–762

    Article  PubMed  CAS  Google Scholar 

  66. Oelkers W. Adrenal insufficiency: current concepts. N Engl J Med 1996; 335 (16): 1206–1212

    Article  PubMed  CAS  Google Scholar 

  67. Findling JW, Aron DC, TyrreH JB. Disorders of adrenocortical insufficiency. In: Greenspan FS, Strewler GJ, editors. Basic & clinical endocrinology. 5th ed. Connecticut: Appleton & Lange, 1997: 334–343

    Google Scholar 

  68. Dunlop D. Eighty-six cases of Addison’s disease. BMJ 1963; 1: 887–891

    Article  Google Scholar 

  69. Barnett AH, Espiner EA, Donald RA. Patients presenting with Addison’s need not be pigmented. Postgrad Med J 1982; 58: 690–692

    Article  PubMed  CAS  Google Scholar 

  70. Soffer LJ, Dorfman RI, Gabrilove JL. The human adrenal gland. Philadelphia: Lea and Febiger, 1961: 256–275

    Google Scholar 

  71. Mountjoy KG. The human melanocyte stimulating hormone receptor has evolved to become “super-sensitive” to melanocortin peptides. Mol Cen Endocrinol 1994; 102 (1–2): R7–11

    Article  CAS  Google Scholar 

  72. Hunt G, Todd C, Kyne S, et al. ACTH stimulates melanogenesis in cultured human melanocytes. J Endocrinol 1994; 140 (1): R1–R3

    Article  PubMed  CAS  Google Scholar 

  73. Parker LN. Addison’s disease and Cushing’s syndrome. In: Parker LN, editor. Adrenal androgens in clinical medicine. San Diego: Academic Press, 1989: 158–174

    Google Scholar 

  74. Zelissen PMJ, Bast EJEG, Croughs RJM. Associated autoimmunity in Addison’s disease. J Autoimmun 1995; 8: 121–130

    Article  PubMed  CAS  Google Scholar 

  75. Grinspoon SK, Biller BM. Laboratory assessment of adrenal insufficiency. J Clin Endocrinol Metab 1994; 79: 923–931

    Article  PubMed  CAS  Google Scholar 

  76. Malchoff CD, Carey RM. Adrenal insufficiency. In: Bardin CW, editor. Current therapy in endocrinology and metabolism. 6th ed. St Louis: Mosby-Year Book Inc, 1997: 142–146

    Google Scholar 

  77. Thorner MO, Vance ML, Laws ER, et al. The anterior pituitary. In: Wilson JD, Foster DW, Kronenberg HM, et al, editors. Williams textbook of endocrinology. 9th ed. Philadelphia: WB Saunders, 1998: 295–307

    Google Scholar 

  78. Melmed S. Clinical manifestations of acromegaly. UpToDate 1998; 6 (1): 1–5

    Google Scholar 

  79. Davidoff LM. Studies in acromegaly: III. the anamnesis ans symptomatology in one hundred cases. Endocrinology 1926; 10: 461–483

    Article  Google Scholar 

  80. Brown J, Winkelmann RK. Acanthosis nigricans: a study of 90 cases. Medicine 1968; 47 (1): 33–51

    Article  PubMed  CAS  Google Scholar 

  81. Melmed S. Diagnosis of acromegaly. UpToDate 1997; 6 (1): 1–4

    Google Scholar 

  82. Ezzat S. Acromegaly. Endocrinol Metab Clin North Am 1997; 26 (4): 703–723

    Article  PubMed  CAS  Google Scholar 

  83. Carr BR. Disorders of the ovaries and female reproductive tract. In: Wilson JD, Foster DW, Kronenberg HM, et al, editors. Williams textbook of endocrinology. 9th ed. Philadelphia: WB Saunders, 1998: 795–799

    Google Scholar 

  84. Taylor AE. Polycystic ovary syndrome. Endocrinol Metab Clin North Am 1008; 27 (4): 877–902

    Article  Google Scholar 

  85. Franks S. Polycystic ovary syndrome. N Engl J Med 1995; 333 (13): 853–861

    Article  PubMed  CAS  Google Scholar 

  86. Vance ML. Hypopituitarism. N Engl J Med 1994; 330 (23): 1651–1662

    Article  PubMed  CAS  Google Scholar 

  87. Dagher HN, Aboujaoude ZC, Jabbour SA. Chronic urticaria: an unusual initial manifestation of primary hyperparathyroidism. Endocr Pract 2002; 8 (1): 47–49

    PubMed  Google Scholar 

  88. Goltzman D. Hypoparathyroidism. In: Favus MJ, editor. Primer on the metabolic bone diseases and disorders of mineral metabolism. 3rd ed. Philadelphia: Lippincott-Raven, 1996: 220–223

    Google Scholar 

  89. Strewler GJ. Mineral metabolism & metabolic bone disease. In: Greenspan FS, Strewler GJ, editors. Basic & clinical endocrinology. 5th edn. Connecticut: Appleton & Lange, 1997: 288–289

    Google Scholar 

  90. Sutphin A, Fuller A, McCune DJ. Five cases (three in siblings) of idiopathic hypoparathyroidism associated with moniliasis. J Clin Endocrinol 1943; 3: 625–634

    Article  Google Scholar 

  91. Bilezikian JP. Primary hyperparathyroidism: when to observe and when to operate. Endocrinol Metab Clin North Am 2000; 29 (3): 465–478

    Article  PubMed  CAS  Google Scholar 

  92. American Diabetes Association. Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 1998; 21 (S1): S5–S19

    Google Scholar 

  93. Muner SA, Winkelman RK. Necrobiosis lipoidica diabeticorum, a clinical and pathological investigation of 171 cases. Arch Dermatol 1966; 93 (3): 272–281

    Article  Google Scholar 

  94. Cruz PD, Hud JA. Excess insulin binding to insulin-like growth factor receptors: proposed mechanism for acanthosis nigricans. J Invest Dermatol 1992; 98 (6 Suppl.): 82S–85S

    Article  Google Scholar 

  95. Matsuoka L Y, Wortsman J, Goldman J. Acanthosis nigricans. Clin Dermatol 1993; 11: 21–25

    Article  PubMed  CAS  Google Scholar 

  96. Macaron C, Winter RJ, Traisman HS, et al. Vitiligo and juvenile diabetes mellitus. Arch Dermatol 1977; 113 (11): 1515–1517

    Article  PubMed  CAS  Google Scholar 

  97. Dawber RPR. Vitiligo in mature-onset diabetes. Br J Dermatol 1968; 80 (5): 275–278

    Article  PubMed  CAS  Google Scholar 

  98. Stawiski MA, Voorhees JJ. Cutaneous signs of diabetes mellitus. Cutis 1976; 18 (3): 415–421

    PubMed  CAS  Google Scholar 

  99. Fleischmajor R, Lara N. Scleredema adultorum: a histochenical and biochemical study. Arch Dermatol 1965; 92: 643–652

    Article  Google Scholar 

  100. Cohen BA, Wheeler CE, Briggman RA. Scleredema of Buschke and diabetes mellitus. Arch Dermatol 1970; 101: 27–35

    Article  Google Scholar 

  101. Clark CV, Pentland B, Ewing DJ, et al. Decreased skin wrinkling in diabetes mellitus. Diabetes Care 1984; 7 (3): 224–227

    Article  PubMed  CAS  Google Scholar 

  102. Lithner F. Lesions of the legs in diabetics and in patients with familial amyloidosis and polyneuropathy. Acta Med Scand Suppl 1976; 589: 1–23

    PubMed  CAS  Google Scholar 

  103. McCulloch DK. Basic insulin regimens in diabetes mellitus. UpToDate 2003; 11 (1): 1–6

    Google Scholar 

  104. Jabbour SA, Goldstein BJ. Improving disease management with new treatments for type 2 diabetes mellitus. Clin Geriatr 2001; 9 (5): 157–168

    Google Scholar 

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  1. Division of Endocrinology, Diabetes and Metabolism, Thomas Jefferson University, 211 South 9th Street, Ste 600, Philadelphia, Pennsylvania, 19107, USA

    Serge A. Jabbour

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Jabbour, S.A. Cutaneous Manifestations of Endocrine Disorders. Am J Clin Dermatol 4, 315–331 (2003). https://doi.org/10.2165/00128071-200304050-00003

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