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PubMed This is a summary of 20 peer-reviewed journal articles Updated
Endocrinology · Graves' Disease Extrathyroidal Manifestations

Eyes and Skin: Managing Extrathyroidal Symptoms

At a Glance

Graves' disease can cause autoimmune symptoms outside the thyroid, most notably Thyroid Eye Disease (TED) and Graves' dermopathy. These eye and skin issues are driven by antibodies and can worsen even if thyroid hormone levels are normal, making specialized care and smoking cessation critical.

While Graves’ disease is primarily known for its effect on the thyroid, the same autoimmune process can also target the tissues behind the eyes and the skin on the lower legs. These are known as extrathyroidal manifestations [1]. It is important to understand that these conditions are driven by the immune system, not just the level of thyroid hormone in your blood. This means that eye or skin symptoms can appear or progress even if your thyroid levels are perfectly normal [2].

Thyroid Eye Disease (TED)

Thyroid Eye Disease (TED), also called Graves’ ophthalmopathy, occurs when antibodies (TRAb) attack the fat and muscle tissues behind the eye [1]. This causes inflammation, swelling, and a buildup of complex sugars (hyaluronan) that can push the eye forward [3].

Staging and Assessment

Doctors use two main tools to evaluate TED and decide on the best treatment path:

  1. Clinical Activity Score (CAS): This measures activity—how much active inflammation is happening right now [4]. A point is given for symptoms like:

    • Pain behind the eye or pain when moving the eye [5].
    • Redness of the eyelids or the white of the eye [6].
    • Swelling of the eyelids or the “caruncle” (the small pink bump in the inner corner of the eye) [7].
    • A high CAS (typically 3 or more out of 7) indicates the disease is “active” and may respond well to anti-inflammatory treatments [4].

  2. EUGOGO Severity Scale: Developed by the European Group on Graves’ Orbitopathy, this measures severity or the impact on your life [4]:

    • Mild: Minor impact on daily life; often managed with lubrication (eye drops) and lifestyle changes [8].
    • Moderate-to-Severe: Significant impact, such as double vision (diplopia) or significant bulging (proptosis) [4][9].
    • Sight-Threatening: Rare, occurring when the optic nerve is compressed or the cornea is severely exposed [4].

The Role of Smoking

Smoking is the single most important modifiable risk factor for TED [10]. If you smoke, you are significantly more likely to develop eye disease, and your eye disease is more likely to be severe and resistant to treatment [11]. Smoking increases oxidative stress in the eye sockets, which fuels the inflammatory “fire” [12]. Quitting smoking is one of the most powerful things you can do to protect your vision [13].

Graves’ Dermopathy (Pretibial Myxedema)

A less common but related condition is Graves’ dermopathy, also known as pretibial myxedema [14]. It is caused by the same antibodies that affect the eyes and thyroid [15].

  • Appearance: It usually appears as a reddish, lumpy thickening of the skin on the shins or tops of the feet [16]. The skin may have a texture similar to an orange peel (peau d’orange) [17].
  • Relationship to TED: Dermopathy is often associated with more severe cases of eye disease [18]. While it is usually painless and primarily a cosmetic concern, severe cases can cause discomfort or interfere with footwear [17].

Because both TED and dermopathy involve the same biological pathways (specifically the IGF-1 receptor), new treatments are being developed that can help manage both conditions simultaneously [19][20].

Common questions in this guide

Can I get Thyroid Eye Disease if my thyroid hormone levels are normal?
Yes, Thyroid Eye Disease can develop or progress even when your thyroid hormone levels are normal. The eye symptoms are driven by an autoimmune response targeting the tissues behind your eyes, not just the amount of thyroid hormone in your blood.
What does a Clinical Activity Score (CAS) measure for Thyroid Eye Disease?
The Clinical Activity Score measures the amount of active inflammation happening in your eyes right now. Doctors use this score, based on symptoms like eye pain, redness, and swelling, to determine if anti-inflammatory treatments will be effective for you.
How does smoking affect Graves' disease eye symptoms?
Smoking is the most significant preventable risk factor for Thyroid Eye Disease. It increases oxidative stress and inflammation, making you much more likely to develop severe eye disease that resists treatment. Quitting smoking is one of the best ways to protect your vision.
What is Graves' dermopathy?
Graves' dermopathy, also known as pretibial myxedema, is a skin condition caused by the same antibodies that affect the thyroid and eyes. It typically appears as reddish, thickened, lumpy skin on the shins or tops of the feet, sometimes resembling an orange peel.
When should I see a specialist for my Graves' eye symptoms?
You should see an ophthalmologist or neuro-ophthalmologist if you notice early signs like a gritty feeling in your eyes, persistent morning puffiness, double vision, or pain when moving your eyes. Early assessment helps prevent more severe complications.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What is my current Clinical Activity Score (CAS), and does it indicate that my eye disease is in an 'active' inflammatory phase?
  2. 2.Based on the EUGOGO categories, how would you classify the severity of my eye disease?
  3. 3.Should I be seen by a specialist neuro-ophthalmologist or an orbital surgeon who has experience with TED?
  4. 4.Is my Graves' dermopathy (pretibial myxedema) linked to the severity of my eye disease, and what are the best topical treatments for it?
  5. 5.If I am a smoker, what specific cessation resources can you provide that are tailored for patients with autoimmune thyroid conditions?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (20)
  1. 1

    Teprotumumab: The First Approved Biologic for Thyroid Eye Disease.

    Hwang CJ, Eftekhari K

    International ophthalmology clinics 2021; (61(2)):53-61 doi:10.1097/IIO.0000000000000353.

    PMID: 33743528
  2. 2

    Lower limb pain and edema due to thyroid dermopathy: an unusual presentation of Graves disease in an adolescent patient.

    Berlingieri DM, Moras LA, Scliar C

    Archivos argentinos de pediatria 2023; (121(2)):e202202615 doi:10.5546/aap.2022-02615.eng.

    PMID: 36378230
  3. 3

    Pathophysiology of thyroid-associated orbitopathy.

    Lee ACH, Kahaly GJ

    Best practice & research. Clinical endocrinology & metabolism 2023; (37(2)):101620 doi:10.1016/j.beem.2022.101620.

    PMID: 35181241
  4. 4

    Updates on Treatment in Thyroid Eye Disease for the Neurologist.

    Alryalat SA, Alasheh A, Salim QA, Yaaqba N

    Neurologic clinics 2026; (44(2)):321-335 doi:10.1016/j.ncl.2025.12.002.

    PMID: 41922040
  5. 5

    Magnetic resonance imaging in thyroid eye disease: Signal intensity ratio to measure disease activity.

    Rath S

    Indian journal of ophthalmology 2022; (70(5)):1446-1447 doi:10.4103/ijo.IJO_365_22.

    PMID: 35502005
  6. 6

    Assessment of thyroid-associated ophthalmopathy activity using corrected standardised uptake value maximum (SUVmax) and uptake ratios from 99Tcm-diethylene triamine pentaacetic acid single photon emission computed tomography/computed tomography (99Tcm-DTPA SPECT/CT) imaging.

    Sun J, Ma L, Wang M, Yuan X

    Clinical radiology 2025; (86()):106946 doi:10.1016/j.crad.2025.106946.

    PMID: 40450787
  7. 7

    Inter-observer Variability of Clinical Activity Score: Assessments in Patients With Thyroid Eye Disease.

    Perros P, Žarković M, Pearce SH, et al.

    American journal of ophthalmology 2023; (252()):94-100 doi:10.1016/j.ajo.2023.03.027.

    PMID: 37028695
  8. 8

    Evaluation of the Graves' Orbitopathy-Specific Quality of Life Questionnaire in the Mainland Chinese Population.

    Zeng P, Fan SX, Li ZJ, et al.

    Journal of ophthalmology 2019; (2019()):7602419 doi:10.1155/2019/7602419.

    PMID: 31011452
  9. 9

    Factors Associated with Response to Intravenous Glucocorticoids in Active Moderate-to-Severe Thyroid Eye Disease.

    Baczewska N, Alexopoulou O, Constantinescu SM, et al.

    Thyroid : official journal of the American Thyroid Association 2025; (35(4)):424-432 doi:10.1089/thy.2024.0629.

    PMID: 40053436
  10. 10

    Risk Factors of Thyroid Eye Disease.

    Lee MH, Chin YH, Ng CH, et al.

    Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2021; (27(3)):245-253 doi:10.1016/j.eprac.2020.11.011.

    PMID: 33655885
  11. 11

    Ocular conditions and dry eye due to traditional and new forms of smoking: A review.

    Makrynioti D, Zagoriti Z, Koutsojannis C, et al.

    Contact lens & anterior eye : the journal of the British Contact Lens Association 2020; (43(3)):277-284 doi:10.1016/j.clae.2020.02.009.

    PMID: 32111452
  12. 12

    The Effect of Smoking on Mitochondrial Biogenesis in Patients With Graves Ophthalmopathy.

    Yuksel N, Yaman D, Tugce Pasaoglu O, Pasaoglu H

    Ophthalmic plastic and reconstructive surgery 2020; (36(2)):172-177 doi:10.1097/IOP.0000000000001514.

    PMID: 31789788
  13. 13

    Radioiodine therapy and Graves' disease - Myths and reality.

    Plazinska MT, Sawicka-Gutaj N, Czarnywojtek A, et al.

    PloS one 2020; (15(1)):e0226495 doi:10.1371/journal.pone.0226495.

    PMID: 31929534
  14. 14

    Insidious-Onset Indurated Plaques on the Shins.

    Agrawal R, Knabel D, Fernandez AP

    Dermatopathology (Basel, Switzerland) 2021; (8(2)):185-189 doi:10.3390/dermatopathology8020024.

    PMID: 34204035
  15. 15

    Histopathological Evidence of Thyroid Dermopathy and its Correlation with Thyroid-Associated Orbitopathy in Patients with Graves' Disease having Normally Appearing Pretibial Skin: A Case-Control Study.

    Mishra A, Chakraborty PP, Jana S, et al.

    Indian journal of endocrinology and metabolism 2022; (26(2)):141-148 doi:10.4103/ijem.ijem_504_21.

    PMID: 35873939
  16. 16

    Pretibial Myxedema Masquerading as a Venous Leg Ulcer.

    Herskovitz I, Hughes O, MacQuhae F, Kirsner RS

    Wounds : a compendium of clinical research and practice 2017; (29(3)):77-79.

    PMID: 28355140
  17. 17

    Graves' disease thyroid dermopathy: a case report.

    Tashkandi L, Alsagheir A, Alobaida S, Alhuthil R

    Journal of medical case reports 2024; (18(1)):164 doi:10.1186/s13256-024-04462-x.

    PMID: 38582878
  18. 18

    De Novo Extra-Thyroidal Manifestations of Graves' Disease presenting 16 Years after Total Thyroidectomy for Thyroid Cancer.

    Kwee A, Yong KL, Seah LL, Chng CL

    Journal of the ASEAN Federation of Endocrine Societies 2021; (36(2)):216-219 doi:10.15605/jafes.036.02.08.

    PMID: 34966209
  19. 19

    Resolution of pretibial myxedema with teprotumumab in a patient with Graves disease.

    Varma A, Rheeman C, Levitt J

    JAAD case reports 2020; (6(12)):1281-1282 doi:10.1016/j.jdcr.2020.09.003.

    PMID: 33294564
  20. 20

    Teprotumumab for Treatment of Pretibial Myxedema.

    Reyes MP, Cabrera J, Singh J, Turnbull D

    JCEM case reports 2023; (1(1)):luac037 doi:10.1210/jcemcr/luac037.

    PMID: 37908268

This page provides educational information about eye and skin symptoms related to Graves' disease. Always consult your endocrinologist, ophthalmologist, or dermatologist for proper diagnosis and personalized treatment.

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