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Hertoghe Sign – Causes and Clinical Meaning

The Hertoghe sign refers to the loss or thinning of the outer third of the eyebrows and is a clinical indicator of hypothyroidism or other systemic conditions.

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Things worth knowing about "Hertoghe Sign"

The Hertoghe sign refers to the loss or thinning of the outer third of the eyebrows and is a clinical indicator of hypothyroidism or other systemic conditions.

What Is the Hertoghe Sign?

The Hertoghe sign describes the characteristic loss or thinning of the outer (lateral) third of the eyebrows. It is named after the Belgian physician Eugene Hertoghe, who first described this clinical finding in association with hypothyroidism (underactive thyroid). In clinical practice, it serves as a potential indicator of an underlying medical condition and always warrants further diagnostic evaluation.

Causes

The Hertoghe sign can result from a variety of diseases and conditions. The most common causes include:

Hypothyroidism (underactive thyroid): A deficiency of thyroid hormones disrupts hair growth cycles, leading to loss of the lateral eyebrows.
Alopecia areata: An autoimmune condition in which the immune system attacks hair follicles, causing patchy hair loss including in the eyebrow area.
Atopic dermatitis (eczema): Chronic inflammation and repeated rubbing or scratching of the eyebrow area can cause local hair loss.
Leprosy: In endemic regions, damage to peripheral nerves caused by Mycobacterium leprae can result in eyebrow loss.
Systemic lupus erythematosus (SLE): This autoimmune disease can cause hair loss in various areas, including the eyebrows.
Nutritional deficiencies: Deficiencies in zinc, biotin, or iron can impair hair growth.
Age-related changes: Natural thinning of the outer eyebrows can occur as a physiological process in older adults.

Symptoms and Clinical Presentation

The Hertoghe sign itself is a clinical finding rather than a standalone symptom. It presents as visible hair loss in the lateral portion of one or both eyebrows. Additional symptoms depend on the underlying cause:

Hypothyroidism: Fatigue, weight gain, cold intolerance, dry skin, constipation, and generalized hair thinning.
Atopic dermatitis: Itching, redness, and scaly skin, particularly in the skin folds.
Alopecia areata: Well-defined, round patches of hair loss on the scalp, eyebrows, or other hair-bearing areas.

Diagnosis

The Hertoghe sign is diagnosed clinically through visual inspection of the eyebrows. To identify the underlying cause, further diagnostic steps are necessary:

Blood tests: TSH, free T3 and free T4 to assess thyroid function; complete blood count, ferritin, zinc, and biotin levels.
Autoantibody testing: Anti-TPO antibodies if Hashimoto thyroiditis is suspected; ANA if lupus is considered.
Dermatological evaluation: Trichoscopy or skin biopsy if alopecia areata or another dermatological condition is suspected.
Medical history: Detailed patient history including medications, family history, and associated symptoms.

Treatment

Treatment is always directed at the underlying cause:

Hypothyroidism: Hormone replacement therapy with levothyroxine (L-thyroxine); successful treatment may lead to regrowth of the lateral eyebrows.
Alopecia areata: Topical or systemic corticosteroids, immunotherapy, or JAK inhibitors depending on severity.
Atopic dermatitis: Topical corticosteroids, calcineurin inhibitors, biologic agents (e.g., dupilumab), and consistent skin care.
Nutritional deficiencies: Targeted supplementation of the deficient nutrient after laboratory confirmation.

In general, if the underlying cause is successfully treated, the Hertoghe sign may be reversible and eyebrow regrowth can occur. However, if hair follicles have been permanently damaged, complete recovery may not always be possible.

Clinical Significance

The Hertoghe sign is a valuable clinical indicator that should not be overlooked during physical examination. It is particularly useful in endocrinological and dermatological practice as a simple, non-invasive screening finding. It serves as a reminder that external changes such as hair loss can reflect systemic diseases that require targeted treatment.

References

Fatourechi V. - Subclinical hypothyroidism: an update for primary care physicians. Mayo Clinic Proceedings, 2009.
Wolff K., Johnson R.A., Saavedra A.P. - Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. 8th edition, McGraw-Hill Education, 2017.
Tosti A., Piraccini B.M. - Diagnosis and Treatment of Hair Disorders. Taylor and Francis, 2006.

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