Systemic Lupus Erythematosus
Patients with an autoimmune-related thyroid disease are at increased risk of other autoimmune diseases, such as systemic lupus erythematosus (SLE), which may yield additional skin findings.3 It is estimated that 6% of patients with lupus have hypothyroidism and 1% have hyperthyroidism11; however, the prevalence of subclinical thyroid disease and positive thyroid autoantibodies, which are major risk factors for subsequent SLE development, appear to be more prevalent, reported to affect 11.5% and 17% of patients, respectively.12
Up to 85% of patients with SLE have skin involvement.13 Common skin findings include malar rash (pictured), photosensitivity, discoid rash, and oral ulcers. Patients might also have alopecia and other symptoms commonly observed in patients with thyroid disorders. Because of such overlapping symptoms and the relatively high risk of thyroid disorders in patients with SLE, it has been recommended that patients with SLE be routinely monitored for autoimmune thyroid disease.13 Image credit: ISM / CID
Hypothyroidism: General Skin Findings
Hypothyroidism is most common in women 60 and older, but can affect both sexes at any age.6 Symptoms vary based on the severity of the hormone deficiency and on whether the hypothyroidism is the result of an autoimmune disease or occurs secondary to a nonautoimmune disorder, with autoimmune etiology being most strongly associated with skin manifestations.5
Common cutaneous findings in patients with hypothyroidism include rough dry skin with fine scales, most often on the extensor extremities.3 Skin might also be cold and pale with a yellow hue to the palms, soles, and nasolabial folds due to increased carotene in the dermis.2 In severe cases, patients can develop generalized myxedema (pictured), an edema-like skin condition caused by increased glycosaminoglycan deposition in the skin.2 In these cases, skin appears swollen, dry, and waxy, and there is easy bruising and poor wound healing. Image Credit: Martin Rotker
Hyperthyroidism: General Skin Findings
Women are at higher risk of hyperthyroidism than men, although both sexes can be affected, with risk greatest in patients with a family history of Graves disease or other thyroid disorders.7 In patients with hyperthyroidism, epidermal thinning is the most commonly reported skin manifestation.8 Other skin anomalies include softness, excessive perspiration (ie, hyperhidrosis; pictured), and warmth, causing skin to feel like that of an infant.3 Itching, generalized pruritus, chronic urticaria, vitiligo, and diffuse skin pigmentation have also been reported.8 Dermal changes most commonly result from autoimmunity, rather than from hormones directly affecting the skin.3
Nail changes are often observed in patients with thyroid disorders and can increase their risk of fungal nail infections.9,10 In patients with hypothyroidism, nails may be slow-growing, thin, striated, and brittle, whereas patients with hyperthyroidism may develop a more concave contour and have yellowing or browning of the nail plate.5 Onycholysis, a painless separation of the nail from the nail bed, has been reported in both conditions, but is more common in hyperthyroidism.5,9 In patients with hyperthyroidism, onycholysis usually begins in the fourth or fifth nail, and the condition is referred to as Plummer’s nails.9 Although onycholysis can have multiple etiologies, including nail trauma, it has been recommended that patients with unexplained onycholysis be screened for asymptomatic thyroid disease.9 Image Credit: Clinical Photography, Central Manchester University Hospitals NHS Foundation Trust, UK / Science Source
Hair changes are another common finding in patients with thyroid disorders. In patients with hypothyroidism, hair can become thin, dry, coarse, and brittle, often resulting in accelerated hair loss.10 Patients also have a longer duration and higher percentage of hairs in the telogen phase, the resting phase after the hair has fallen out and during which the follicle remains inactive before a new hair growth cycle begins, further contributing to diffuse or partial (pictured) alopecia of the scalp. There may also be loss of hair on the outer third of the eyebrow and diminished body hair. As with nail changes in these patients, there is a higher risk of fungal infection, with Candida folliculitis sometimes reported.3
Patients with hyperthyroidism often have fine or soft hair.3 Loss of pigment or premature development of gray hair have also been reported as early symptoms.4 As with hypothyroidism, patients may have partial or diffuse alopecia. Image credit: Dr P. Marazzi / Science Source
Psoriasis and Psoriatic Arthritis
Psoriasis is a chronic relapsing/remitting autoimmune skin condition that results in itchy, thickened, scaly patches, papules, and plaques that often affect the elbows, knees, scalp, palms, and soles of the feet.16 Approximately 30% of patients with psoriasis develop psoriatic arthritis, and a strong association with autoimmune thyroid disorders has been reported in these patients. Psoriasis alone might also be a risk factor for thyroid disorders, but studies have been somewhat inconsistent and further studies are needed to better establish the connection. Psoriatic arthritis alone, however, appears to increase the risk of thyroid diseases, with good consistency reported between studies of adult patients.16
It is unclear if routine thyroid screening would be beneficial in patients with psoriasis, but it might be warranted in patients with psoriatic arthritis and in patients with both conditions, especially in the setting of risk factors for thyroid disorders. Image credit: BSIP
Scleroderma is a rare autoimmune disease that leads to hardening of connective tissue; it is estimated that fewer than 500,000 people in the United States have scleroderma.17 The etiology of scleroderma remains unclear; however, many patients have a personal or family history of thyroid diseases and other autoimmune disorders. In one small study, 7 of 18 patients with systemic scleroderma had a familial history of thyroid disease and 8 of 18 had a thyreopathy.18 Because of the high prevalence of thyroid disorders in patients with systemic scleroderma, routine screening for thyroid disorders might be warranted, especially in patients with risk factors for thyroid disorders and/or atypical clinical follow-up.18
Despite being a heterogeneous disorder, almost all patients have skin involvement manifest as a loss of cutaneous elasticity followed by skin thickening.19 Hands and fingers are often the first areas affected. Calcinosis, pruritus from dry skin, and joint contracture are other common findings.19 Image credit: ISM / CID
Vitiligo causes the skin to lose its pigment, resulting in lighter patches of skin and a mottled appearance. It can also affect the hair, eyes, and inside of the mouth. The extent and rate of pigment loss cannot be predicted, but the condition is generally most noticeable in people with darker skin.
Results from a systematic review and meta-analysis of more than 24,000 patients with vitiligo suggest a significantly increased risk of thyroid disorders in these patients.20 Thyroid disease was 1.9 times more likely, autoimmune thyroid disease 2.5 times more likely, and the presence of thyroid-specific antibodies 5.2 times more likely in these patients vs nonvitiligo controls. Risk of an autoimmune thyroid disease was found to increase with age.20 The study investigators do not recommend routine thyroid screening of patients with vitiligo, but suggest clinicians treating these patients remain on high alert for symptoms of thyroid disease. Image Credit: ISM / CID
According to the American Thyroid Association (ATA), approximately 20 million Americans have a thyroid disease, and up to 60% of affected individuals are unaware of their condition.1 Since the 1800s, thyroid disorders have been known to cause a variety of skin manifestations, which may sometimes be the first sign of an underlying thyroid problem.2
Thyroid hormones are known to affect multiple aspects of cutaneous biology, including the epidermis, dermis, nails, and hair, all of which may show changes in people with thyroid disorders.2 Cutaneous manifestations can vary significantly based on patients’ thyroid functional status and whether the manifestation is from thyroid hormones directly affecting skin tissue or secondary to another autoimmune disease associated with thyroid dysfunction.2-4 Subsequently, thyroid disorders may result in a wide array of cutaneous findings, making a high index of suspicion crucial in ensuring an accurate and timely diagnosis. In many cases, treatment of the underlying thyroid disorder improves or resolves the skin problems.5
Compiled by Christina Loguidice
- American Thyroid Association (ATA). General information/press room. www.thyroid.org/media-main/about-hypothyroidism/Accessed November 11, 2017.
- Safer JD. Thyroid hormone action on skin. Curr Opin Endocrinol Diabetes Obes. 2012;19(5):388-393.
- Safer JD. Thyroid hormone action on skin. Dermatoendocrinol. 2011;3:211-215.
- Kasumagic-Halilovic E. Thyroid disease and the skin. Ann Thyroid Res. 2014;1(2):23-26.
- Takir M, Özlü E, Köstek O, et al. Skin findings in autoimmune and nonautoimmune thyroid disease with respect to thyroid functional status and healthy controls. Turk J Med Sci. 2017;47(3):764-770.
- Mayo Clinic. Hypothyroidism (underactive thyroid). Accessed November 11, 2017.
- Mayo Clinic. Hyperthyroidism (overactive thyroid). Accessed November 11, 2017.
- Antonini D, Sibilio A, Dentice M, Missero C. An intimate relationship between thyroid hormone and skin: regulation of gene expression. Front Endocrinol (Lausanne). 2013;4:104.
- Gregoriou S. Nail disorders and systemic disease: what the nails tell us. J Fam Pract. 2008;57(8):509-514.
- Heymann WR, ed. Thyroid disorders with cutaneous manifestations. London, UK: Springer-Verlag; 2008;73-102.
- The Johns Hopkins Lupus Center. Signs, symptoms, and co-occurring conditions. Accessed November 11, 2017.
- Appenzeller S, Pallone AT, Natalin RA, Costallat LT. Prevalence of thyroid dysfunction in systemic lupus erythematosus. J Clin Rheumatol. 2009;15(3):117-119.
- Uva L, Miguel D, Pinheiro C, et al. Cutaneous manifestations of systemic lupus erythematosus. Autoimmune Diseases. doi:10.1155/2012/834291
- Kavala M, Kural E, Kocaturk E, et al. The evaluation of thyroid diseases in patients with pemphigus vulgaris. The ScientificWorldJournal. 2012;146897. www.hindawi.com/journals/tswj/2012/146897/ Accessed November 20, 2017.
- Firooz A, Mazhar A, Ahmed AR. Prevalence of autoimmune diseases in the family members of patients with pemphigus vulgaris. J Am Acad Dermatol. 1994;31(3 Pt1):434-437.
- Ruffilli I, Ragusa F, Benvenga S, et al. Psoriasis, psoriatic arthritis, and thyroid autoimmunity. Front Endocrinol. 2017;8:139.
- The Johns Hopkins Scleroderma Center. Understanding scleroderma. www.hopkinsscleroderma.org/scleroderma/Accessed November 11, 2017.
- Mourier-Clavreul MC, Rousset H, Claudy A. Scleroderma and thyroid diseases [in French]. Ann Dermatol Venereol. 1989;116(10):701-706.
- Krieg TK, Takehara K. Skin disease: a cardinal feature of systemic sclerosis. Rheumatology. 2009;48(3):iii14-iii18.
- Vrijman C, Kroon MW, Limpens J, et al. The prevalence of thyroid disease in patients with vitiligo: a systematic review. Br J Dermatol. 2012;167(6):1224-1235.