# Sneddon-Wilkinson Disease as a Manifestation of Severe Hypothyroidism

## TL;DR

An elderly woman with severe hypothyroidism presented with a skin condition called Sneddon-Wilkinson Disease, highlighting the importance of checking thyroid levels in similar cases.

## Contribution

This case report highlights a rare manifestation of severe hypothyroidism as Sneddon-Wilkinson Disease before myxedema coma.

## Key findings

- Sneddon-Wilkinson Disease was diagnosed through biopsy and linked to severe hypothyroidism.
- The patient's mental status and rash improved after levothyroxine and steroid treatment.
- Thyroid hormone levels were significantly outside the normal range, indicating severe hypothyroidism.

## Abstract

A Caucasian female in her 80s with a past history of hypothyroidism, chronic kidney disease, lichen sclerosus, and intertrigo presented originally with a pustular rash to an outpatient dermatology office. The patient was treated for intertrigo with nystatin and oral fluconazole before re-presenting four months later with new erythematous plaques and overlying small pustules in the groin, axilla, and inframammary folds. A shave biopsy was taken, and the patient was treated with triamcinolone for plaques on the abdomen and nystatin and hydrocortisone for intertriginous areas. After two weeks, the patient was admitted to the hospital with expressive aphasia and a presumed stroke, and an EEG consistent with metabolic encephalopathy. Her thyroid-stimulating hormone (TSH) level was found to be 29 mlU/L (reference: 0.27-4.20 mlU/L) and T4 level of 0.42 ng/dL (reference: 0.93-1.70 ng/dL), reflective of severe hypothyroidism. The patient was started on IV levothyroxine and methylprednisolone, with improvement in mental status and rash within six days of admission to the hospital. A review of initial biopsy histology showed subcorneal accumulation of neutrophils with spongiosis, consistent with Sneddon-Wilkinson disease (SWD). SWD commonly manifests as painless superficial pustular lesions arising within erythematous plaques. It is found to often be associated with multiple comorbidities, including thyroid disorders. Given this unique presentation of SWD prior to the onset of severe hypothyroidism and myxedema coma, clinicians should consider examining thyroid hormone levels in such patients to rule out hyperthyroidism and hypothyroidism.