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July 1, 2020

Necrolytic Acral Erythema in Association With Hypothyroidism

Author Affiliations
  • 1Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
  • 2Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
  • 3Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
JAMA Dermatol. 2020;156(11):1268-1270. doi:10.1001/jamadermatol.2020.1976

Necrolytic acral erythema (NAE) is a relatively rare cutaneous marker of underlying hepatitis C virus infection in which zinc dysregulation is believed to play an important role.1 In this article, we describe 5 hepatitis C virus–seronegative patients who developed NAE lesions shortly after the detection of hypothyroidism.

Five patients with hypothyroidism presented with classic NAE lesions on the dorsal side of the hands and legs, with extensive disease in 2 patients. The mean (SD) duration of the lesions at the time of presentation was 2.6 (0.5) weeks, with rapid progression of disease in all patients. All of them were seronegative for HIV as well as the hepatitis B and hepatitis C viruses. The pathogenesis of hypothyroidism was variable in all patients. Patients 1, 2, and 3 had Graves disease and underwent radioactive iodine ablation of the thyroid gland; patient 4 had a total thyroidectomy for papillary carcinoma followed by a low-dose, planar whole-body scan with sodium iodide I 131 (131I). Patient 5 (Figure 1 and Figure 2) had been diagnosed as having primary hypothyroidism but had stopped taking levothyroxine suddenly (Table). All patients had clinical hypothyroidism at the time of presentation, with a mean (SD) thyrotropin level of 26.6 (28.7) mIU/L (range: 7-74 mIU/L; normal: 0.2-4.2 mIU/L) and mean (SD) serum zinc level of 49.0 (15.7) μg/dL (range: 32.0-69.9 μg/dL; normal: 75.2-120.9 μg/dL; to convert to μmol/L, multiply by 0.153). The interval between the detection of hypothyroidism and the appearance of NAE ranged from 1 to 6 weeks. The duration was much shorter in patients receiving radioactive iodine ablation (1-2 weeks) (Table).

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