From the Department of Dermatology and Internal Medicine, School of Medicine, Chungnam University Hospital, Taejon, South Korea
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A 20-year-old Korean woman presented in August 1999 with a 3-month history of multiple, tiny papules on the periorbital and malar areas (Fig. 1a). She had noted hyperhidrosis for the preceding 6 months, even at room temperature. She had been well and had received no medication prior to her first visit to our clinic. Physical examination showed yellow colored, translucent, small papules, as well as finger tremor, exophthalmos, and a goiter. Histologic examination demonstrated cystic structures in the dermis lined with two layers of cuboidal epithelial cells (Fig. 2). The epidermis was normal and the rete ridges were partially effaced. Immunohistochemical studies revealed that the epithelial cells of the cyst wall were carcinoembryonic antigen (CEA) positive but S-100 protein negative.Because a goiter and finger tremor were noted on physical examination, hyperthyroidism was suspected. Thyroid function test results were: triiodothyronine (T3), 8.0 ng/mL (normal range, 0.7–1.9 ng/mL); free thyroxine (T4), 8.1 ng/mL (0.7–1.9 ng/mL); T4, 35 µg/dL (6.0–11.8 µg/dL); thyroid-stimulating hormone (TSH), 0.04 IU/mL (0.25–4.0 IU/mL); positive for anti-TSH receptor antibody. On the basis of these findings, the patient was diagnosed with Graves’ disease and treated with methimazole, 40 mg/day. As the patient's symptoms improved, the therapeutic dose was decreased to 20 mg/day. Four months after the beginning of treatment, the free T4 and T3 values had returned to the normal range (Table 1). The skin lesions, finger tremor, and hyperhidrosis had also disappeared. Exophthalmos was improved, but still present (Fig. 1b).