An integrated approach to the treatment of pretibial myxedema based on pulse therapy with prednisolone and electrical neuromyostimulation (FREMS-therapy) in a patient with Graves’ disease and thyroid eye disease

Graves’ disease (GD) is one of the urgent problems of modern endocrinology, characterized by a high frequency, polysystemic damage to the body, a steadily progressive course, diagnostic difficulties, a high degree of disability and often resistance to therapy. The manifestations of the disease include: thyrotoxicosis syndrome with impaired lipid and carbohydrate metabolism, and activation of multiple organ pathology in the form of thyroid eye disease (TED), pretibial myxedema, cardiovascular insufficiency, acropathy, lesions of the nervous, osteoarticular system, and other lesions. The development of multiple organ pathology can have a different sequence, different time intervals and different degrees of severity. Any developments in the direction of clarifying the etiopathogenetic, clinical diagnostic and treatment-rehabilitation measures are of undoubted significance. We present a clinical case of GD, TED and pretibial myxedema, in which an integrated approach was tested in the tactics of treating pretibial myxedema (a combination of pulse therapy with prednisolone and FREMS-therapy), as a result of which positive results were obtained within a short time.

1. Bartalena L, Fatourechi V. Extrathyroidal manifestations of Graves’ disease: a 2014 update. J Endocrinol Invest. 2014;37(8):691-700. doi: https://doi.org/10.1007/s40618-014-0097-2

2. Daumerie C, Ludgate M, Costagliola S, et al. Evidence for thyrotropin receptor immunoreactivity in pretibial connective tissue from patients with thyroid-associated dermopathy. Eur J Endocrinol. 2002;146(1):35-38. doi: https://doi.org/10.1530/eje.0.1460035

3. Schwartz KM, Fatourechi V, Ahmed DD, et al. Dermopathy of Graves’ disease (pretibial myxedema): long-term outcome. Clin Endocrinol Metab. 2002;87(2):438-446. doi: https://doi.org/10.1210/jcem.87.2.8220

4. Fatourechi V. Pretibial myxedema: pathophysiology and treatment options. Am J Clin Dermatol. 2005;6(5):295-309. doi: https://doi.org/10.2165/00128071-200506050-00003

5. Martinenghi S, Caretto A, Losio C. et al. Successful treatment of dercum’s disease by transcutaneous electrical stimulation: A case report. Medicine Baltimore. 2015;94(24):e950. doi: https://doi.org/10.1097/MD.0000000000000950

6. Bevilacqua M, Dominguez LJ, Barrella M, Barbagallo M. Induction of vascular endothelial growth factor release by transcutaneous frequency modulated neural stimulation in diabetic polyneuropathy. J Endocrinol Invest. 2007;30(11):944-947. doi: https://doi.org/10.1007/BF03349242

7. Bosi E, Bax G, Scionti L, et al. Frequency-modulated electromagnetic neural stimulation (FREMS) as a treatment for symptomatic diabetic neuropathy: results from a double-blind, randomised, multicentre, long-term, placebo-controlled clinical trial. Diabetologia. 2013;56(3):467-475. doi: https://doi.org/10.1007/s00125-012-2795-7

8. Santamato A, Panza F, Fortunato F, et al. Effectiveness of the frequency rhythmic electrical modulation system for the treatment of chronic and painful venous leg ulcers in older adults. Rejuvenation Res. 2012;15(3):281-287. doi: https://doi.org/10.1089/rej.2011.1236

9. Gandolfi A, Pontara A, Di Terlizzi G, et al. Improvement in clinical symptoms of scleredema diabeticorum by frequency-modulated electromagnetic neural stimulation: A case report. Diabetes Care. 2014;37(11):e233-e234. doi: https://doi.org/10.2337/dc14-0730

10. Andersson U, Tracey KJ. A new approach to rheumatoid arthritis: treating inflammation with computerized nerve stimulation. Cerebrum. 2012;2012:3.

11. Bartalena L, Baldeschi L, Boboridis K, et al. The 2016 European Thyroid Association/European Group on Graves’ Orbitopathy Guidelines for the Management of Graves’ Orbitopathy. Eur Thyroid J. 2016;5(1):9-26. doi: https://doi.org/10.1159/000443828

12. Ismailova DS, Belovalova IM, Grusha YO, Sviridenko NY. Orbital decompression in the system of treatment for complicated thyroid eye disease: case report and literature review. Int Med Case Rep J. 2018;11(1):243-249. doi: https://doi.org/10.2147/IMCRJ.S164372

13. Varma A, Rheeman C, Levitt J. Resolution of pretibial myxedema with teprotumumab in a patient with Graves disease. JAAD Case Reports. 2020;6(12):1281-1282. doi: https://doi.org/10.1016/j.jdcr.2020.09.003

14. Petit L, Catinis A, Richard E, Silverberg J. A case of pretibial myxedema treated with teprotumumab. JAAD Case Reports. 2021;(16):134-136. doi: https://doi.org/10.1016/j.jdcr.2021.08.026

15. Engin B, Gümüşel M, Özdemir M, Çakir M. Successful combined pentoxifylline and intralesional triamcinolone acetonide treatment of severe pretibial myxedema. Dermatol Online J. 2007;13(2):16. doi: https://doi.org/10.5070/D38ND2C6TR

16. Silapunt S, Agwu AV, Migden MR. Severe pretibial myxedema refractory to systemic immunosuppressants. Cutis. 2019;104(3):E1-E3.

17. Takasu N, Higa H, Kinjou Y. Treatment of pretibial myxedema (PTM) with topical steroid ointment application with sealing cover (steroid occlusive dressing technique: steroid ODT) in Graves’ patients. Intern Med. 2010;49(7):665-669. doi: https://doi.org/10.2169/internalmedicine.49.2617