Hypothyroidism is a prevalent endocrine disorder characterized by insufficient thyroid hormone production, leading to a variety of systemic manifestations. In India, the prevalence of hypothyroidism is estimated to be approximately 11%, which is notably higher compared to Western populations [1].

Cutaneous manifestations are common in hypothyroidism and can serve as early indicators of the disease. These manifestations include dry, coarse skin (xerosis), hair loss, brittle nails, and myxedema. For instance, a study by Puri et al. reported that dry, coarse skin was the most common cutaneous symptom, observed in 65.22% of patients, followed by hair loss in 42.6% and puffy edema in 38.48% [2,3].

The pathophysiology behind these cutaneous changes is primarily due to decreased metabolic activity and reduced peripheral circulation associated with hypothyroidism. This leads to alterations in skin texture, hair growth, and nail integrity. Additionally, the accumulation of mucopolysaccharides in the dermis results in myxedema, contributing to skin thickening and puffiness [4-6].

In the Indian context, where iodine deficiency remains a significant public health issue, understanding the cutaneous manifestations of hypothyroidism is crucial. These manifestations can aid in early detection and management, especially in regions where access to advanced diagnostic facilities may be limited.

This study aimed to evaluate the spectrum of cutaneous changes in newly diagnosed hypothyroid patients in the subtropical region of India, thereby contributing to the existing body of knowledge and facilitating early diagnosis and intervention.

MATERIAL AND METHODS

Study Design and Setting: This was a prospective, observational study conducted at a tertiary care hospital in the subtropical region of India from January 2025 to June 2025. Informed consent was obtained from all participants.

Study Population: The study included newly diagnosed adult patients (≥18 years) with clinical hypothyroidism, confirmed by elevated serum Thyroid-Stimulating Hormone (TSH) levels and low Free Thyroxine (FT4) levels, as per the American Thyroid Association guidelines [7]. Patients with a history of thyroid surgery, radioactive iodine therapy, or those on thyroid hormone replacement therapy prior to the study were excluded.

Sample Size: Based on a study by Vartika et al. [4], which reported that 67.83% of hypothyroid patients exhibited xerosis, a common cutaneous manifestation, and considering a 95% confidence level and a 5% margin of error, the required sample size was calculated to be approximately 400 patients. This sample size was deemed sufficient to detect significant associations between cutaneous changes and hypothyroidism.

Data Collection: Demographic and clinical data were collected through structured interviews and medical records. A comprehensive dermatological examination was performed to identify and document cutaneous manifestations, including:

• Skin changes: xerosis, thinning, myxedema, carotenemia
• Hair changes: diffuse hair loss, coarse hair, brittle hair, madarosis
• Nail changes: longitudinal striations, brittle nails, slow growth
• Pigmentary changes: pallor, xanthelasma, acanthosis nigricans
• Oedematous changes: puffiness of face, hands, and feet

Statistical Analysis: Data were analyzed using SPSS version 26.0. Descriptive statistics were used to summarize demographic and clinical characteristics. The prevalence of each cutaneous manifestation was calculated. Associations between categorical variables were assessed using the Chi-square test or Fisher’s exact test, as appropriate. A p-value < 0.05 was considered statistically significant.

RESULTS

A total of 400 newly diagnosed hypothyroid patients were included in the study. The mean age was 38.4 ± 12.7 years, with the majority being female (258/400, 64.5%) and urban residents (236/400, 59.0%) (Table 1)

Cutaneous manifestations were observed in a high proportion of patients. The most prevalent skin changes were xerosis (68.0%), followed by dry, coarse hair (49.5%), diffuse hair loss (43.0%), and brittle nails (27.0%). Other notable features included pallor (36.0%), myxedema (24.0%), facial puffiness (22.0%), carotenemia (13.0%), and madarosis (11.0%) (Table 2).

When analyzed by sex, the prevalence of most cutaneous features was slightly higher among females, although differences were not statistically significant. Xerosis was present in 69.8% of females versus 64.8% of males (p = 0.31). Similarly, diffuse hair loss, dry coarse hair, brittle nails, and myxedema showed no significant sex-based differences (Table 3).

Age-wise analysis revealed that xerosis and hair loss were common across all age groups, with a slightly higher prevalence in the 46–60 years age group (xerosis 73.5%, hair loss 46.9%). Myxedema prevalence increased with age, reaching 40.0% in patients above 60 years (Table 4).

Table 1: Demographic Profile of Study Population (n = 400)

Table 2: Prevalence of Cutaneous Manifestations (n=400)

Table 3: Association of Cutaneous Manifestations with Sex

Table 4: Association of Cutaneous Manifestations with Age Group

DISCUSSION

Our study observed a notably high prevalence of cutaneous manifestations among newly diagnosed hypothyroid patients residing in the Indian subtropical region. The most frequently reported dermatological features included xerosis, characterized by dry and rough skin; dry, coarse hair; diffuse hair loss affecting the scalp and body hair; and myxedema, manifesting as non-pitting swelling and thickening of the skin. These observations are consistent with findings from earlier studies conducted in various regions of India, which similarly reported xerosis, hair abnormalities, and mucinous skin changes as prominent features in hypothyroid individuals [2,3,8-10].

The underlying pathophysiology of these cutaneous manifestations is primarily linked to the systemic metabolic derangements seen in hypothyroidism. Reduced thyroid hormone levels lead to decreased basal metabolic rate and diminished peripheral blood flow, which collectively impair nutrient and oxygen delivery to the skin and adnexal structures. Consequently, there are marked alterations in epidermal turnover, keratinization, and hair follicle cycling, resulting in xerosis, coarse hair, and diffuse hair loss. Furthermore, the deposition of glycosaminoglycans, particularly hyaluronic acid and chondroitin sulfate, in the dermis leads to mucopolysaccharide accumulation, contributing to myxedema and the characteristic thickened, puffy appearance of the skin [11,12]. Impaired sebaceous and sweat gland function in hypothyroid patients further exacerbates skin dryness and coarseness.

In our cohort, the prevalence of cutaneous manifestations was higher among female patients, reflecting the well-established higher incidence of hypothyroidism in females. Nonetheless, statistical analysis did not demonstrate significant differences in the spectrum or severity of dermatological features between males and females. Age-stratified analysis revealed that xerosis and hair loss were prevalent across all age groups, with a modestly higher occurrence in individuals aged 46–60 years. Notably, the prevalence of myxedema demonstrated an age-dependent increase, reaching 40.0% in patients aged over 60 years, suggesting progressive dermal glycosaminoglycan accumulation with advancing age [13-16].

These findings highlight the clinical relevance of dermatological assessment in patients suspected of hypothyroidism. Recognizing characteristic skin and hair changes can serve as early, non-invasive indicators of thyroid dysfunction. Prompt identification and diagnosis facilitated by careful cutaneous examination may allow earlier initiation of thyroid hormone replacement therapy, thereby mitigating systemic complications and improving overall patient outcomes.

CONCLUSION

Cutaneous manifestations are highly prevalent in newly diagnosed hypothyroid patients in the subtropical Indian region. Xerosis, hair changes, and myxedema are the most common features, while nail and pigmentary changes are less frequent. These findings highlight the importance of thorough dermatological examination in hypothyroid patients, as early recognition of skin, hair, and nail changes can aid in diagnosis and prompt management.

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