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a 42-year - old indian male had multiple small circumscribed wrinkled sacs like lesions on the shoulders and upper back of 4 months duration ( fig .
skin biopsy was taken for histopathological examination and revealed minimal dermal perivascular chronic inflammatory cells infiltrate ( fig .
elastic stain ( verhoef - van gieson ) showed loss of elastic fibers in the superficial dermis ( fig .
direct immunofluorescence ( dif ) was negative for iga , igg , igm , c1q , c3 and fibrinogen .
the patient did not have any symptoms or show any sings of antiphospholipid syndrome ( aps ) , and screening for antiphospholipid antibodies ( anticardiolipin profile , anti--2-glycoprotein , igg and igm , and lupus anticoagulant ) were all negative .
antinuclear antibody ( ana ) , ena screen ( smb , smd , rnp-70 , and rnp - a , rnp - c , ssa / ro52 , ssa / ro60 , ssb / la , cenp - b , scl-70 , jo-1 , ribosomal p and histones ) were negative .
thyroid panel test showed normal free thyroxine and thyroid stimulating hormone , but the patient had a positive high titer of thyroid peroxidase antibody ( anti - tpo antibody ) > 116 iu/ ml .
there are numerous reports and studies that link primary anetoderma ( pa ) to lupus erythematosus , but the relation has not been clearly established [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ]
. moreover , there are isolated repots of pa and autoimmune diseases like primary hypothyroidism , grave 's disease , addison 's disease , sjogren 's syndrome , alopecia areata , vitiligo [ 14 , 18 , 19 ] and multiple sclerosis .
now , there is a growing body of evidence to consider pa as a cutaneous sign of positive antiphospholipid antibodies with or without fulfilling the criteria of aps [ 16 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ] . in our case
, there is a high titer of antithyroid peroxidase antibodies , which is consistent with autoimmune thyroiditis .
this is in accordance with the work of hodak et al .   who described a case of pa with grave 's disease , positive lupus anticoagulant and autoimmune hemolysis .
it is important to mention that grave 's disease in the study of hodak et al .  
had started 5 years after the onset of the pa . in our study , there were no clinical signs or symptoms of thyroid disease at the time of diagnosis ; also free thyroxine and thyroid stimulating hormone were in a normal range , but we have to take the short duration of onset of pa in our case into consideration . also , bergman et al .   described a case of primary hypothyroidism that developed 3 years after the onset of anetoderma . from our point of view and the aforementioned literature
we have to think of pa as a cutaneous sign of autoimmunity and patients should be examined and carefully tested for autoimmune diseases , especially for antiphospholipid antibodies , lupus erythematosus and also thyroid antibodies .
patients should also be followed up because associated autoimmune diseases may develop later in the course of the disease , maybe years after the onset of anetoderma .
anetoderma is a rare elastolytic disorder characterized by circumscribed areas of flaccid skin due to the loss of elastic tissue in the dermis . 
 primary anetoderma is frequently observed in patients with autoimmune diseases or abnormalities especially with antiphospholipid antibodies with or without antiphospholipid syndrome . in this case report 
 we discuss a patient with primary anetoderma with positive antithyroid peroxidase antibodies , which is consistent with autoimmune thyroiditis .