According to the American Thyroid Association, 6% of the population have some type of thyroid disease and 60% of them (~12 million people) are unaware of it. Assuming the same rate applies in Canada, 2.3 million people in Canada have thyroid disease and almost 1.4 million people are unaware of it. Since changes in the skin may be one of the first clinical signs of hypothyroidism [2] and are often important indications of its progression [4], this article outlines how some of those skin changes may appear.
DISCLAIMER (August 26, 2022): The information in this post should in no way be taken as a recommendation to self-diagnose, self-interpret skin symptoms or diagnostic tests, or self-treat any suspected disorder. It is essential that people who suspect they may have symptoms of any condition consult with their doctor, as only a medical doctor can diagnose and treat.
NOTE: This article also contains aspects of my personal story which are clearly marked. My personal experience is not objective data. The pictures are provided only so that people can better understand what some skin symptoms of hypothyroidism may look like. Many more pictures are available in clinical online.
INTRODUCTION: My interest in hypothyroidism is more than academic, as I was recently diagnosed with it. I realize in retrospect that I missed almost all the early signs because I didn’t know what the range of possible symptoms could be. Just as my interest in hyperinsulinemia and type 2 diabetes was birthed in my own diagnosis and eventual partial remission, my interest in this hypothyroidism is no different. Since hypothyroidism can be dangerous if left untreated, my goal in writing this series of articles is to help people know the wide range of symptoms that may be associated with it, and to seek medical attention for themselves or their loved one, when necessary.
As outlined in the article Symptoms of Hypothyroidism Mistakenly Blamed on Aging, people think it is normal for ‘older adults’ to have body aches, joint pain, fatigue, to feel chilled when others do not, experience constipation, hair loss, be forgetful, or to experience depression. However, these are NOT typical signs of aging but ARE common symptoms of hypothyroidism.
In retrospect, in my case, these types of symptoms came long after the skin symptoms, but cutaneous symptoms were so non-specific that I had no idea they might indicate that something clinical was going on.
Of course, as a Dietitian, I knew that people often gained weight before they were diagnosed with hypothyroidism, and that they needed to take one of several medications prescribed as treatment. I knew they had to take their medication a half an hour before eating but until recently, my support was limited to teaching them what hypothyroidism is, the nutrients of importance in thyroid function, and foods and beverages that may impact thyroid function.
Until recently, I didn’t know that undiagnosed hypothyroidism can be dangerous and can progress to a myxedema crisis that can be fatal, with a death rate between 20-60%, even with treatment [3].
Until today, I had no idea that the majority of people with thyroid disease (60%) are undiagnosed [1].
Putting these two sets of statistics together was concerning to me. Since many of the symptoms of hypothyroidism such as joint and muscle pain, difficulty getting up from a seated position, or feeling cold are often discounted as normal signs of aging, I wanted people to also know what some of the skin symptoms of hypothyroidism are in the hope that is might help them put the clues together, and seek medical attention.
Skin Symptoms Associated with Hypothyroidism
As mentioned in a previous article about the role of hormones in metabolic disease, thyroid hormones act on every organ system of the body, and their affect on the skin is no exception. Some skin symptoms such as myxedema don’t appear until much later in the progression of hypothyroidism, while other appear early on.
In this article, I will describe the later symptoms first because they are hallmarks of the progression of disease and indicate that getting medical attention is important. In my own case, it was the symptoms associated with myxedema that made me begin to realize that the tiredness and achy muscles and sore joints that I had been experiencing for over a year was more than post-Covid symptoms.
As explained in Symptoms of Hypothyroidism Mistakenly Blamed on Aging, myxedema describes advanced hypothyroidism that occurs when the condition is left untreated or inadequately treated and is also applied to hypothyroidism’s effects on the skin, where it looks puffy and swollen and takes on a waxy consistency [4].
[Personal note: It was me looking for clinical answers this morning that resulted in me stumbling across the some of the other skin symptoms associated with hypothyroidism. I wanted to know how long it would take since beginning treatment with thyroid hormone medication for the myxedema to resolve in my legs.]
NOTE: these photos are for illustrative purposes only. Photos of myxedema in the clinical literature are available but are copyrighted. It is for this reason that I am posting my photos only as example, or illustrations.
Below is a photo showing the change in appearance in my left leg from November 3, 2021 (left), to July 16, 2022 (middle), to August 26, 2022 (right).
The photo on the left was taken by me last November while I was doing some stretches. It was still on my phone in mid-July when I took a picture of the swelling in my lower legs and ankles caused by mucin accumulating in the skin. The photo on the right was taken this morning, and while much of the swelling has been reduced, I am still unable to pinch any skin on my legs due to the remaining mucin. I have read that it can take 6 – 8 months for this to resolve.
It has been only 2 months since I began treatment for hypothyroidism, beginning with a very low dose. The above photo shows what I looked like 2 ¾ months ago at my son’s wedding, and how quickly the myxedema in my face resolved with treatment.
What Causes the Skin Change Known as Myxedema
Myxedema is one several skin significant changes associated with the progression of hypothyroidism. A recently updated dermatology textbook describes myxedema as ‘skin that is cold and pale with abnormally widespread dryness (xerosis) and where a diffuse loss of hair (alopecia) may be present [5].’
When I first saw my doctor after my son’s wedding at the beginning of June, he pointed this out on my legs and said that the cold, waxy skin, along with the swelling is “benchmark symptom” of hypothyroidism. He showed me how it was impossible to pinch and lift any skin on my legs and that pressing on it left no ‘dent’ mark. This lack of a dent means the type of edema (swelling) is “non-pitting edema.” Pitting edema occurs in many other conditions, but this non-pitting edema, along with the cold, waxy skin is characteristic of progressing hypothyroidism. The coldness of the skin is the result in the drop in body temperature due to decreased metabolism [2] and is another hallmark symptom of hypothyroidism, discussed in a previous article. The swelling is caused by the accumulation of mucin in the skin.
Mucin is a type of glycoprotein (a protein with a side chain of hyaluronic acid, a sugar molecule) [5] which is naturally produced in the skin. Hyaluronic acid normally binds water to collagen, trapping it in the skin and is injected into the skin by dermatologists to cause aging skin to appear plump, moist and younger looking. The problem is, in hypothyroidism mucin accumulates under the skin, giving it that “tight, waxy” texture. (I would describe it as feeling like an over-inflated balloon). The accumulation of mucin around hair follicles contributes to the resulting hair loss on the arms and legs (and other areas where it occurs).
[Personal Note: if you look at the composite picture of my left foot (above), you can see in the right hand photo taken this morning (more than 2 months after beginning thyroid hormone medication) that I still cannot pinch any skin on my legs. While my face has improved, there is still significant improvement yet to occur in my legs, and other parts of my body. ]
Other Skin Symptoms of Hypothyroidism
In addition to myxedema, other skin changes that are associated with hypothyroidism include;
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- dry skin (xerosis)
- thin scaly skin
- carotinemia
- purpura
- telogen effluvium (hair loss)
- decrease sweating
- poor wound healing
As explained in an earlier article, since the presentation of symptoms in hypothyroidism varies so much between individuals, symptoms that were “early” for me, may not be for others, and may not appear at all.
Purpura is caused when small blood vessels burst, resulting in blood pooling just under the skin. It looks a bit like a bruise, but without pain or swelling and it does not change colour in time. Purpura is a non-serious skin hemorrhage that is almost always a symptom of something else and looks like small, reddish-purple spots just beneath the skin’s surface.
[Personal account: This morning, when I saw the term “purpura” it jumped out at me. Since May of 2021, I have had a large purple area on my left ankle that I had first attributed to a particularly grueling hike I did in Maple Ridge, BC with one of my young adult sons. I noticed it when I got home, as did my son, and I assumed it would clear up on its own, but it never did. When I saw my doctor right after my son’s wedding, I showed it to him and he nodded as if to take note, but didn’t say anything. I now know that in my case, it was one of the very early skin signs of hypothyroidism. I thought I had taken photos of what my purple ankle looked like at its worse, but I may have deleted them because I thought it was simply leftover damage to blood vessels from a hike. The good news is, that two months after beginning thyroid hormone treatment, the purpura is ~75% resolved.]
- August 20, 2022: purpura 75% resolved, thin dry skin, telogen effluvium (hair loss) yet to be resolved
Another early symptom of hypothyroidism for me, was telogen effluvium, a loss of hair on my arms and legs and to a lesser extent, on my scalp.
[Personal account: Last summer I was joking with a family member that one of the advantages of getting older was no longer needing to shave my legs. I didn’t realize until recently that the loss of hair on my legs and arms as long as two years ago was NOT a perk of aging (like no longer having a “period”), but was an early symptom of hypothyroidism! I also didn’t realize that decreased sweating wasn’t a benefit of aging, either. I feel stupid in retrospect, but I wasn’t taught it and when I looked it up it said that hair on the body “thins” as one ages, so I thought it was normal. I hadn’t realized that I had NO hair on my arms and legs. Two months after beginning thyroid medication, that is beginning to change. I feel like a pubescent boy excited by his first facial hair.
I mentioned the dry skin in previous posts, so won’t do so again here, but that was a very early sign for me. Again, I thought it was a normal part of aging.]
Another term that jumped out at me this morning, was the term carotinemia. This is where beta-carotene accumulates in the blood and gives skin a yellowish pigmentation. In my case, it was not due to eating too much beta-carotene rich foods like carrots, squash or sweet potato, but was a skin symptom of hypothyroidism.
Two days ago, I posted the photo below on social media. I now understand the significance of what I wrote;
“Update from A Dietitian’s Journey – Part II: It’s been exactly 2 ½ months since my son’s wedding and 2 months since I began thyroid treatment. I think what is most noticeable is that the yellowish skin colour is gone.”
How my Clinical Practice is Impacted
Just as my clinical practice changed 5 years ago when I came to understand what hyperinsulinemia was, and how early clinical signs of developing type 2 diabetes are evident as long as 20 years before diagnosis, it is changing again as a result of what I am learning about hypothyroidism.
Understanding the wide range of clinical and subclinical symptoms that people may have leads me to ask additional questions, to look at lab test results differently, and to ask for additional ones if it seems clinical warranted. While it is beyond the scope of practice of a Dietitian to diagnose any disease or to treat hypothyroidism, I am more aware of what to look and this helps me to refer people back to their doctor if I feel there may be a clinical concern.
Final Thoughts…
The list of skin symptoms in hypothyroidism in this article is by no means exhaustive. There are others discussed in the literature that present, particularly as the disease progresses. Since the goal of this article was to present symptoms that may present early or with advancing hypothyroidism, additional symptoms are beyond the scope of this article.
If you think that you, or someone you know may have symptoms of hypothyroidism, please consult with a medical doctor.
More Info
If you would like more information about the services I provide people who are newly diagnosed with hypothyroidism, please send me a note through the Contact Me form, above.
To your good health!
Joy
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References
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- American Thyroid Association, Prevalence and Impact of Thyroid Disease, https://www.thyroid.org/media-main/press-room/, accessed August 26, 2022
- Kasumagic-Halilovic E. Thyroid Disease and the Skin. Annals Thyroid Res. 2014;1(2): 27-31.
- Elshimy G, Chippa V, Correa R. Myxedema. [Updated 2022 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545193/#_NBK545193_pubdet_
- Medical News Today, What is Myxedema and How is it Treated, April, 22, 2022, https://www.medicalnewstoday.com/articles/321886
- Patterson, JW, Weedon’s Skin Pathology, Cutaneous Mucinoses, Elsevier Canada; 5th edition (April 20, 2020)
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