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EndocrineGraves diseaseICD-10 E05.9 / L98.5

Pretibial myxoedema

Localised myxoedema · thyroid dermopathy

Pretibial myxoedema is a cutaneous manifestation of autoimmune thyroid disease, most commonly Graves disease, occurring in 1-5% of Graves patients and almost always in association with thyroid eye disease. It is characterised by symmetric pretibial accumulation of glycosaminoglycans (hyaluronic acid) producing waxy plaques / nodules. It is an important DDx for necrobiosis lipoidica, lipodermatosclerosis, elephantiasis nostras and chronic lymphoedema in skin-oncology practice.

CurrentLast reviewed 16 May 2026
Clinical image of Pretibial myxoedema
Pretibial myxoedema. Image sourced from DermNet New Zealand. Used under CC BY-NC-ND 4.0. No endorsement implied.

Pathogenesis

  • TSH-receptor antibodies (TRAb) stimulate fibroblasts; cross-react with shin fibroblasts → glycosaminoglycan / hyaluronic acid accumulation.
  • Strong association with Graves disease — usually post-treatment, when hyperthyroidism may be controlled.
  • Concomitant ophthalmopathy (Graves orbitopathy) in ≥95%; thyroid acropachy is uncommon, present in only a minority.
  • Rarely occurs in Hashimoto thyroiditis.

Clinical features

  • Symmetric pretibial waxy infiltrated plaques and nodules; yellow-brown or pink; non-pitting.
  • Variants: diffuse, plaque-type, nodular, elephantiasis-like.
  • Sites: pretibial (commonest), dorsum foot, face, upper limbs (rare).
  • Peau d'orange surface; coarse hair, hyperhidrosis on overlying skin.
  • Pruritus / discomfort variable.
  • Concurrent Graves: exophthalmos, lid lag, goitre, tachycardia, thyroid bruit; thyroid acropachy (clubbing + soft-tissue swelling + periosteal reaction).

Differentials

  • Necrobiosis lipoidica — yellow-brown atrophic plaques; pretibial; ulceration; diabetes.
  • Lipodermatosclerosis — bilateral "inverted champagne bottle"; chronic venous insufficiency.
  • Lymphoedema / elephantiasis — pitting acutely; non-pitting late.
  • Mucinoses — generalised papular mucinosis, scleromyxoedema.
  • Granuloma annulare (deep).
  • Cellulitis.

Investigations

  • TFT (T3, T4, TSH), TRAb / thyroid-stimulating immunoglobulins.
  • Skin biopsy: dermal mucin (Alcian blue positive), fibrosis, mast cells.
  • Ophthalmology review if visual symptoms; orbital MRI / CT.
  • Radiographs if thyroid acropachy suspected.

Management

  • Optimise thyroid status (does not always resolve dermopathy).
  • Topical: super-potent corticosteroid (clobetasol propionate 0.05%) under occlusion; intralesional triamcinolone 5-10 mg/mL.
  • Compression: graduated stocking / multilayer bandaging.
  • Refractory: IVIG, rituximab, plasmapheresis, octreotide, pentoxifylline — limited evidence; specialist setting.
  • Severe elephantiasic disease: surgical debulking with caution; high recurrence.
  • Smoking cessation (also improves orbitopathy).
  • Multidisciplinary care: endocrinology, ophthalmology, dermatology.

References

  1. Schwartz KM et al. Dermopathy of Graves disease (pretibial myxedema): long-term outcome. J Clin Endocrinol Metab. 2002;87:438-446.
  2. Heyes C et al. Pretibial myxedema: a review of the literature and current treatment options. Am J Clin Dermatol. 2018;19:51-65.
  3. Fatourechi V. Thyroid dermopathy and acropachy. Best Pract Res Clin Endocrinol Metab. 2012;26:553-565.

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