Mucocutaneous manifestations of acquired hypoparathyroidism: An observational study

Abstract

Hypoparathyroidism is a disorder of calcium and phosphorus metabolism due to decreased secretion of parathyroid hormone. Hypoparathyroidism can be hereditary and acquired. Acquired hypoparathyroidism usually occurs following neck surgery (thyroid surgery or parathyroid surgery). Along with systemic manifestations, hypoparathyroidism produces some skin manifestations. Lack of study regarding mucocutaneous manifestations of acquired hypoparathyroidism prompted us to undertake this study. To evaluate the mucocutaneous manifestations of acquired hypoparathyroidism. An observational study done in a tertiary care hospital of Kolkata by comprehensive history taking, through clinical examination and relevant laboratory investigations. Twenty-one patients were included in the study. The commonest form of acquired hypoparathyroidism was neck surgery (thyroidectomy and parathyroidectomy operation). Mucocutaneous manifestations were present in 76.19% of patients. The most frequent mucocutaneous manifestation was found in the hairs like the loss of axillary hair (61.9%), loss of pubic hair (52.38%), coarsening of body hair (47.62%), and alopecia areata (9.52%). The nail changes noted were brittle and ridged nail, followed by onycholysis, onychosezia, and onychomedesis. The most common skin features were xerotic skin in 11 patients (52.38%), followed by pellagra-like skin pigmentation, pustular psoriasis and acne form eruption, bullous impetigo, etc. Mucosa was normal in all the cases excepting the one which showed oral candidiasis.

INTRODUCTION

Hypoparathyroidism is a disorder of calcium, phosphorus, and bone metabolism due to decreased secretion of parathyroid hormone.[1] It can be hereditary or acquired. In earlier decades, hypoparathyroidism secondary to neck surgery was more common than hereditary one, but in recent days with the improvement of surgical skills and techniques the prevalence of surgery induced hypoparathyroidism has reduced. Along with different systemic manifestations like dystonia, chorioathetoid movement, seizures, papilloedema, raised intracranial tension, hypoparathyroidism produces different mucocutaneous manifestations such as oral candidiasis, onycholysis, brittle nails, loss of axillary and pubic hairs, dry skin, and pigmentation.[1–3] Pustular psoriasis can also occur in hypoparathyroidism due to hypocalcemia induced by the disease.[3,4] Relative lack of study regarding mucocutaneous manifestations of acquired hypoparathyroidism prompted us to undertake this study.

AIMS

To evaluate the mucocutaneous manifestations of acquired hypoparathyroidism.

MATERIALS AND METHODS

The study was conducted in the Department of Dermatology and Endocrinology of a tertiary care hospital of Kolkata from March 2006 to February 2011 by consecutive patients of acquired hypoparathyroidism attending the outpatient Department of School of Tropical Medicine, Kolkata, by proper history taking, through mucocutaneous examination including hair and nails and relevant investigation like KOH mount. The data were collected in a prestructured case data sheet and were analyzed by appropriate statistical tools.

RESULTS

Twenty-one patients were included in this study. The age of the patients ranged from 31 to 65 years with a mean of 47.3 years. Female-to-male ratio was 1.1:1. Sixteen patients (76.19%) developed acquired hypoparathyroidism following thyroid surgery, four patients (19.04%) following parathyroid surgery, and one patient following radiation. Out of 21 patients, 16 of them (76.19%) showed different forms of mucocutaneous manifestations. The most frequent manifestation was found in the hairs; they were the loss of axillary hair (61.90%, 13 patients of 21), followed by loss of pubic hair (52.38%, 11 patients of 21), coarsening of body hair (47.62%, 10 patients of 21), and alopecia areata (9.52%, 2 patients of 21). Among the nail changes, brittle and ridged nail as the commonest manifestation in eight patients (38.09%), followed by onycholysis in six patients (28.57%), onychosezia in four patients (19.05%), and onychomedesis in one patient (4.76%). The most common skin features were dry skin in 11 patients (52.38%), followed by pellagra-like skin pigmentation, pustular psoriasis, and acne form eruption in 2 patients each (9.52%), and bullous impetigo in 1 patient. Mucosa was normal in all the cases excepting the one which showed oral candidiasis.

DISCUSSION

Acquired hypoparathyroidism usually results from inadvertent surgical removal of parathyroid gland. Previously acquired hypoparathyroidism was much more common than hereditary one, but nowadays improvement of surgical technique reduces the prevalence of acquired hypoparathyroidism. In some instances, acquired hypoparathyroidism is due to secondary fibrotic changes in the neck following neck surgery which reduces the blood flow to the parathyroid glands. In the past, the most frequent cause of acquired hypoparathyroidism was thyroid surgery, but in recent days it mainly occurs after surgery of hyperparathyroidism when the surgeon removes too much thyroid tissue during the surgery.[5] Other causes of acquired hypoparathyroidism include radiation, hemodialysis, hemosiderosis, repeated blood transfusion, and hemochromatosis. In this study, the most common cause of acquired hypoparathyroidism was postthyroidectomy hypoparathyroidism. Previously described skin changes of acquired hypoparathyroidism include dry, keratotic skin, coarse hair, loss of axillary or pubic hair, brittle and ridged nail, onycholysis, and candidiasis. Pellagra-like skin pigmentation occurs, but are rare.[1,2] In our study, we got higher percentage of hair problems like loss of axillary hair (61.9%), loss of pubic hair (52.38%), and coarsening of hair (47.62%). Also, we got two patients of alopecia areata which started after the parathyroid surgery. Nail problems were also very frequent in this study like brittle nail, onychomycosis, and onycholysis. One patient showed complete loss of two toe nails. We got oral candidiasis in 4.76% of patients which was much less than it was described in hereditary hypoparathyroidism. Dry rough keratotic skin described in the previous literature was also present in this study.[3] Two patients of this study had pustular psoriasis which confirms the previous observations that hypocalcemia induced by hypoparathyroidism precipitate pustular psoriasis.[4,6] In our study we got few new skin problems, which were not described previously like complete loss of nail, acne for eruptions on trunk, and alopecia areata.