Graves’ Disease and the Manifestations of Thyrotoxicosis
DeGroot LJ.
ncbi.nlm.nih.gov/books/NBK2...
THE SKIN
Cutaneous manifestations are nearly always present when hypermetabolism is significant. The patient feels hot and prefers a cold environment. Active sweating occurs under circumstances that would provoke no response in normal persons. Hand shaking gives a nearly diagnostic impression. The hand of the thyrotoxic person is erythematous, hot, and moist (sometimes actually dripping wet), in a state of hot hyperhydrosis. Although such hands may occasionally be found in other conditions, the finding of a cold hand, dry or moist -- almost excludes hyperfunction of the thyroid. Flushing is also very common, more in younger patients than in older ones. There may be more or less continuous erythema of the face and neck, with superimposed transient blushing. Occasionally diffuse pruritis or urticaria occurs. Urticaria appears to be linked to Graves hyperthyriodisim by some immune mechanism, but so far the causal relation is unknown (276).
The vasomotor system is overactive. Many of these cutaneous manifestations may be considered expressions of or incidental to increased heat elimination.
Redness of the elbows, first noted by Plummer, is frequently present. It is probably the result of the combination of increased activity, an exposed part, and a hyperirritable vasomotor system.
Although the integument is thinned, manifestations due to alteration in the growth of the tissue are less evident. It is possible that the type of fingernail described by Plummer (onycholysis) belongs in this category (Figure 10-7). The process may involve all fingers and toes, but typically begins on the fourth digit of each hand. The free margin of the nail leaves the nail bed, producing a concave or wavy margin at the line of contact. The hyponychium may be ragged and dirty, despite the best efforts at personal hygiene. Plummer's nails are a frequent and interesting clinical finding in Graves' disease. Occasionally the spoon-shaped fingernails of hypochromic anemia are encountered.
Patchy hyperpigmentation, especially of the face and neck, is frequently seen, and occasionally there is a general increase in pigmentation. Most dark-skinned persons detect a definite increase in pigmentation during the onset of thyrotoxicosis, which may be dramatically localized around the eyes.
Patchy vitiligo is found in 7% of patients with Graves' disease, and we have observed several instances of complete loss of pigmentation in association with thyrotoxicosis. These changes are manifestations of associated autoimmunity directed toward melanocytes. The vitiligo, often of the hands and feet, may precede the onset of Graves' disease by years or even decades. Observation of this change is a useful clinical sign when attempting to establish the cause of thyrotoxicosis or exophthalmos.
Hair tends to be fine, soft, and straight. Women may complain that it will not retain a curl. (This complaint is also typical of patients with myxedema.) Temporary thinning of the hair is common, but alopecia is rare. Hair loss is often extreme after marked changes in metabolic rate are induced during therapy. We have seen complete or partial alopecia develop in a few patients with Graves' disease, sometimes in association with urticaria. These changes are believed to be manifestations of autoimmunity directed against the hair follicles.
Peripheral edema, unrelated to congestive heart failure or renal disease, is very common.
Pretibial myxedema (Figure 10-8) and the other remarkable abnormalities of "thyroid acropachy" are discussed in Chapter 12.
Is this a Graves diagnosis?
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Vegetarian with Graves'
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