Calcinosis cutis

Extensive calcinosis cutis complicating radiotherapy

Dystrophic calcinosis cutis is a rare late sequela of radiotherapy, and can cause a significant impact on quality of life. Management of the condition can be challenging. However, we achieved effective symptomatic relief with injection of triamcinolone.

Calcinosis Prevalence in Autoimmune Connective Tissue Diseases-A Retrospective Study

Background/Objectives: Calcinosis cutis is the deposition of insoluble calcium salts, which may cause inflammation, ulceration, pain, and restricted joint mobility. It rarely develops in damaged tissues (dystrophic subtype), most frequently in autoimmune connective tissue diseases (CTDs), but there is very limited data on the prevalence. Also, therapy remains an unsolved issue. In this study, we aimed to collect data on the prevalence of calcinosis in CTD patients to highlight that it is a considerable problem. Methods: A retrospective study was conducted in our department to assess the epidemiology of dystrophic calcinosis in CTDs between January 2003 and January 2024. Results: A total of 839 CTD patients were identified, of whom 56 had calcinosis (6.67%). The mean age of the calcinosis patients at diagnosis of underlying CTD was 41.16 ± 19.47 years. The mean time interval from the onset of calcinosis was 5.96 ± 8.62 years. Systemic sclerosis was the most common CTD complicated by calcinosis (n = 22). Conclusions: Our results are comparable to those reported previously in the literature. Although calcinosis is rare in the overall population, it is a present and unsolved problem in CTD patients. Therefore, further studies are needed on the factors involved in the development and progression of calcinosis as well as its treatment.

Unusual Presentation of Recurrent Calcinosis Cutis in the Right Thumb of a 16-Year-Old Female

Calcinosis cutis is a quite unusual disease represented by abnormal accumulation of calcium salts in the skin and subcutaneous tissues. Repeated cutis calcinosis means recurrent calcium deposition in pre-existing areas. The case report illustrated the case of a 16-year-old female who had recurrent calcium deposits on the base of her right thumb. The patient initially had swelling at the base of her right thumb, which had been present for six months now. The patient described the dorsal solid mass on top of the thumb base, which was painful and had reduced thumb mobility. There was swelling that became painful, specifically located at the same site as the previous surgery, with thumb restriction and superadded infection at the metacarpophalangeal joint. Routine lab tests, including blood tests and rheumatologic and autoimmune work-ups, were normal. Plain radiographs and ultrasound examinations unveiled the characteristics of calcifications in the thumb tissues. A skin biopsy was done and the calcium deposits in subcutaneous tissue were confirmed, matching calcinosis cutis. The approach to the treatment of this condition entailed conservative measures. Some included physiotherapy to correct a flexion deformity, antibiotics, painkillers, and daily dressing. The patient was advised to follow up and to consider excision of the nodules. This case points out the clinical manifestations, investigations, and initial management of available strategies for recurrent calcinosis cutis. Further studies and long-term follow-up are necessary to determine the optimal treatment approaches and outcomes for this rare condition.

Dystrophic Calcinosis Cutis Leading to a Nonhealing Wound in a Patient with Chronic Venous Insufficiency

The presence of bony-appearing fragments and calcifications appearing superficially in a chronic, nonhealing wound raises suspicion for osteomyelitis. When radiological imaging and tissue biopsy of the lesion return negative for osteomyelitis, however, the differentials must be widened to successfully manage and heal a chronic wound. In this report, we discuss a case of an 80-year-old morbidly obese woman with a history of chronic venous insufficiency, hereditary hemochromatosis, and squamous cell carcinoma who presented to the wound clinic with a 5-month history of a nonhealing wound with bony-appearing fragments and calcifications on her left anterior leg status postbiopsy during routine skin examination. Upon clinical correlation with laboratories and imaging, it was determined that the cause of her nonhealing wound was due to dystrophic calcinosis cutis.

Systemic Sodium Thiosulfate as an Adjunct Treatment in Calcinosis: A Retrospective Study

(1) Background: Calcinosis of the skin mainly appears in connective tissue disorders (dystrophic subtype). It may cause inflammation, ulceration, pain, and restricted joint mobility. Management is difficult; sodium thiosulfate is one potential therapeutic agent with promising data on intralesional and topical formulation for smaller calcified lesions. There are very limited data on systemic administration. (2) Methods: A retrospective study was conducted at our department to assess the efficacy of oral and intravenous sodium thiosulfate in dystrophic calcinosis between 2003 and 2023. (3) Results: Seven patients were identified, who received systemic sodium thiosulfate (intravenous or oral). The mean duration of calcinosis at the time of administration was 3.8 ± 4 years (range 0-11). Intravenous sodium thiosulfate was administered in doses of 12.5-25 g two or three times during one week of the month for 4.5 ± 3.9 months on average. Orally, 1-8 g was administered daily for 29.1 ± 40.9 months on average. Four of seven patients had a partial response (57.1%). Despite no complete response, pain, ulceration and inflammation frequency decreased, and sodium thiosulfate prevented further progression in responsive patients. (4) Conclusions: Based on our experience and literature data, systemic sodium thiosulfate may be a potential adjunct therapy in calcinosis, especially if inflamed or ulcerating.

Perforating Calcinosis Cutis as a Complication of Intraosseous Fluid Infusion in the Setting of a Near-Drowning Event

Iatrogenic calcinosis cutis represents a subset of calcinosis cutis resulting secondary to treatments or procedures. We present the first report of calcinosis cutis resulting from the intraosseous infusion and one of a few cases with associated transepidermal elimination. A previously healthy 2-year-old female presented with a new-onset unilateral shin rash 1 week following hospitalization for a near-drowning event. A dermatologic exam revealed multiple small, tender, firm, chalky-white papules with surrounding erythema, in addition to two erythematous macules superior and medial to the papular lesions, corresponding to prior intraosseous access sites. The rash persisted despite trials of topical mupirocin and acyclovir cream, prompting a referral to a dermatologist. An excisional biopsy was performed, revealing circumscribed dermal deposits of acellular basophilic material connected to the overlying epidermis through an invaginated keratin plug. A von Kossa silver stain highlighted the deposits, confirming the diagnosis of perforating calcinosis cutis. The lesions did not recur following the excisional biopsy. Iatrogenic calcinosis cutis may be seen as a complication of the infusion of calcium-containing fluids via intraosseous access, in addition to the more commonly observed peripheral intravenous access. Awareness of this disorder is important in order to distinguish it from an infectious mimic and guide the selection of therapy.

Calcinosis Cutis and Calciphylaxis in Autoimmune Connective Tissue Diseases

Calcinosis represents a severe complication of several autoimmune disorders. Soft-tissue calcifications have been classified into five major types: dystrophic, metastatic, idiopathic, iatrogenic, and calciphylaxis. Autoimmune diseases are usually associated with dystrophic calcifications, including calcinosis cutis, occurring in damaged or devitalized tissues in the presence of normal serum levels of calcium and phosphate. In particular, calcinosis cutis has been described in dermatomyositis, polymyositis, juvenile dermatomyositis, systemic sclerosis, systemic lupus erythematosus, primary Sjögren's syndrome, overlap syndrome, mixed connective tissue disease, and rheumatoid arthritis. Calciphylaxis, a severe and life-threatening syndrome presenting with vascular calcifications and thrombosis, has also been associated with some autoimmune conditions. Due to the potentially disabling character of calcinosis cutis and calciphylaxis, physicians' awareness about the clinical presentation and management of these diseases should be increased to select the most appropriate treatment option and avoid long-term complications. In this review, we aim to analyze the clinical features of calcinosis cutis and calciphylaxis associated with autoimmune diseases, and the main treatment strategies evaluated up to now for treating this potentially disabling disease.

Mobile Subcutaneous Calcinosis Cutis: A Case Report of a Mobile Solitary Subepidermal Calcified Nodule on a Woman's Leg and a Review of Mobile Subcutaneous Tumors

Calcinosis cutis describes the deposition of calcium in the dermis. A case of a 69-year-old woman with idiopathic calcinosis cutis that presented as a mobile subcutaneous nodule is described. The patient had an asymptomatic, firm, mobile subcutaneous nodule on her right lower leg of at least six months duration. The nodule could be easily moved from one location to another. An incisional biopsy was performed. Microscopic examination of the tissue specimen showed islands of basophilic calcium material in dense sclerotic dermal connective tissue establishing the diagnosis of calcinosis cutis. Mobile solitary calcification is an unusual presentation of idiopathic calcinosis cutis. In addition to idiopathic calcinosis cutis, benign mobile subcutaneous tumors have also been derived from adnexal structures of hair follicles and adipose tissue. Hence, not only idiopathic calcinosis cutis, but also subepidermal calcinosis in the ocular adnexa, proliferating trichilemmal cyst with focal calcification, and mobile encapsulated adipose tissue can present as a mobile subcutaneous nodule. The features of idiopathic calcinosis presenting as a mobile subcutaneous nodule as well as the characteristics of other benign mobile subcutaneous tumors are reviewed.

Clinical and ultrasonography follow-up of five cases of calcinosis cutis successfully treated with intralesional sodium thiosulfate

Calcinosis cutis (CC) is characterized by deposit of calcium salts in the skin and subcutaneous tissue; its clinical presentation consists of indurated painful nodules, which can ulcerate and become superinfected. CC treatment remains a challenge, yet successful treatment with intralesional (IL) sodium thiosulfate (STS) has been reported in several CC subtypes. Herein we are reporting on a case series of 5 patients with CC successfully treated with IL-STS. We describe the 18-22 MHz ultrasound characteristics of the lesions and on follow-up after treatment. Ultrasound imaging was useful in guiding IL-STS injections and confirming response to treatment.

Assessment of disease outcome measures in systemic sclerosis

The assessment of disease activity in systemic sclerosis (SSc) is challenging owing to its heterogeneous manifestations across multiple organ systems, the variable rate of disease progression and regression, and the relative paucity of patients in early-phase therapeutic trials. Despite some recent successes, most clinical trials have failed to show efficacy, underscoring the need for improved outcome measures linked directly to disease pathogenesis, particularly applicable for biomarker studies focused on skin disease. Current outcome measures in SSc-associated interstitial lung disease and SSc skin disease are largely adequate, although advancing imaging technology and the incorporation of skin mRNA biomarkers might provide opportunities for earlier detection of the therapeutic effect. Biomarkers can further inform pathogenesis, enabling early phase trials to act as reverse translational studies through the incorporation of routine high-throughput sequencing.

Innate Immunity in Calcinosis Cutis

Calcinosis cutis is the deposition of calcium salts in the skin and subcutaneous tissue, manifesting as variably shaped papules, nodules, and plaques that can substantially impair quality of life. The pathophysiology of calcinosis cutis involves dysregulation of proinflammatory cytokines, leukocytes, and other components of the innate immune system. In some conditions associated with calcinosis cutis, elevated serum calcium, phosphate, and vitamin D may also perturb innate immunity. The mechanisms by which these lead to cutaneous and subcutaneous calcification likely parallel those seen in vascular calcification. The role of aberrant innate immunity is further supported by the association between various autoantibodies with calcinosis cutis, such as anti-MDA5, anti-NXP2, anti-centromere, and anti-topoisomerase I. Treatments for calcinosis cutis remain limited and largely experimental, although mechanistically many therapies appear to focus on dampening innate immune responses. Further research is needed to better understand the innate immune pathophysiology and establish treatment options based on randomized-controlled trials.

Subcutaneous Calcifications in Legs with Chronic Venous Diseases

BACKGROUND

Calcifications in the subcutaneous layer (SCL) have been described by x-rays studies in legs with advanced chronic venous disorders (CVD). However, SCL calcifications are rarely included among the changes CVD-related. The aim of this study was to evaluate the prevalence and morphology of SCL calcifications in legs with CVD of all grades of severity by ultrasonography (US).

MATERIAL AND METHODS

Five hundred legs in 250 patients (148 females and 102 males, mean age 51, range 18-87) referred to the vascular clinic for symptoms and signs of CVD were included. After the Duplex evaluation of deep, superficial, and perforating veins the skin and the SCL were investigated by Duplex sonography. Subjects with other possible cause of SCL calcification were excluded.

RESULTS

According to the CEAP-C classification, 43 legs were classified as C1,189 as C2, 34 as C3, 16 as C4A, 45 as C4B or C, 18 as C5 and finally 16 as C6. Varicose veins were reported in 273 legs, lipodermatosclerosis (LDS) in 79. Subcutaneous calcifications were demonstrated in 35/361 CVD legs in two different locations: in the wall of superficial varicose veins (SVC) or in the subcutaneous tissue unrelated to the path of superficial veins (STC). The SVC were found in 12 out of 273 legs with varicose veins (4.4%). They were found in older patients with severe varicose veins disease (grade 3 of VCSS and disease duration >30 yrs). The STC were found in 24 out of 95 legs in the more advanced CVD stages (C4A-C6 classes). No STC were found in C1, C2, and C3 legs.

DISCUSSION

SVC were found only in legs with severe and long-lasting varicose veins and seem to be related to a chronic severe inflammation of the venous wall. STC are independent from the vein wall and were found only in the damaged areas of legs with severe CVD (C4-C6). They are possibly related to chronic inflammation of the subcutaneous tissue. Their avulsion from the ulcer bed is recommended to facilitate ulcer healing and prevent their recurrence.

Spätmanifeste Kalzinose in Brandnarben: Eine Literaturübersicht und zwei Fallberichte

Calcinosis cutis, die heterotope Ablagerung von Kalziumsalzen in der Haut, wurde in einigen Fällen als spät auftretende Komplikation von Brandnarben beschrieben. Sie unterscheidet sich diesbezüglich von heterotoper Ossifikation, die eine früh einsetzende Komplikation von Brandverletzungen sein kann. Die Diagnose einer Kalzinose kann radiographisch, sonographisch, computertomographisch, magnetresonanztomographisch oder histologisch bestätigt werden. Nahezu alle Fälle einer spätmanifesten Kalzinose bei Brandnarben imponieren als nicht heilendes Ulkus an den unteren Extremitäten in der Nähe der Kontrakturbänder. Es wird diskutiert, dass diese Lokalisation auf die häufigeren Mikrotraumen an den unteren Extremitäten zurückzuführen ist, und dass die Ulzeration aufgrund der Kalziumablagerungen als Fremdkörper auftritt. In unserer Studie betrug das Durchschnittsalter zum Zeitpunkt der Brandverletzung 12,5 ± 8,27 Jahre und die Kalzinose entwickelte sich im Mittel nach einer Zeitspanne von 37,5 ± 14,95 Jahren (das Durchschnittsalter bei Beginn war 50,5 ± 14,53 Jahre). Es gab keinen signifikanten Unterschied zwischen Brandnarben, die mittels Hauttransplantation behandelt wurden, und solchen, bei denen keine Hauttransplantation durchgeführt wurde. Die Ulzera verheilten nach Resektion oder Extraktion der Ablagerungen ohne Rezidiv an derselben Stelle. Im Gegensatz zu früher gemeldeten Fällen beobachteten wir zwei Fälle einer spät einsetzenden Kalzinose ohne Ulzeration bei Brandnarben an den oberen Extremitäten.

Late-onset calcinosis in burn scars: A review of the literature and two case reports

Calcinosis cutis is a heterotopic accumulation of calcium salts in the skin. It has been described as a late‐onset complication of burn scars in a few cases, in contrast to heterotopic ossification, which may be an early‐onset complication of burn injuries. Diagnosis of calcinosis can be confirmed by radiography, ultrasonography, computed tomography, magnetic resonance imaging or histology. Almost all cases of late‐onset calcinosis in burn scars present as non‐healing ulcers on the lower extremities near contracture bands. It has been hypothesized that this localization is due to the more frequent microtrauma of the lower extremities, and that ulceration is due to the presence of calcium deposits as foreign bodies. In our study, the mean age at the time of burn injury was 12.5 ± 8.27 years, and calcinosis developed after a mean time of 37.5 ± 14.95 years (mean age at onset was 50.5 ± 14.53 years). There was no significant difference between burn scars managed with skin grafting and those where skin grafting was not carried out. The ulcers healed after resection or extraction of the deposits without any recurrence at the same site. In contrast to previously reported cases, we observed two cases of non‐ulcerating late‐onset calcinosis in burn scars of the upper extremities.

Dystrophic calcinosis cutis in chronic venous disease of the lower limbs

Abstract Lower limb ulcers secondary to chronic venous disease (CVD) are a significant public health problem in Brazil and account for about 70% of these ulcers. Despite recent technological advances and the various therapeutic options for treatment of these chronic injuries, several factors may be involved in resistance to treatment. Dystrophic calcinosis cutis (DCC) is a rare and often underdiagnosed condition that, when in conjunction with CVD, may be associated with a refractory healing process. In this article, we report a case of DCC in a patient with CVD and discuss its etiology, pathophysiology and possible treatment options.

Calcinose distrófica cutânea na doença venosa crônica de membros inferiores

Lower limb ulcers secondary to chronic venous disease (CVD) are a significant public health problem in Brazil and account for about 70% of these ulcers. Despite recent technological advances and the various therapeutic options for treatment of these chronic injuries, several factors may be involved in resistance to treatment. Dystrophic calcinosis cutis (DCC) is a rare and often underdiagnosed condition that, when in conjunction with CVD, may be associated with a refractory healing process. In this article, we report a case of DCC in a patient with CVD and discuss its etiology, pathophysiology and possible treatment options.

Idiopathic inflammatory myopathies

Idiopathic inflammatory myopathies (IIM), also known as myositis, are a heterogeneous group of autoimmune disorders with varying clinical manifestations, treatment responses and prognoses. Muscle weakness is usually the classical clinical manifestation but other organs can be affected, including the skin, joints, lungs, heart and gastrointestinal tract, and they can even result in the predominant manifestations, supporting that IIM are systemic inflammatory disorders. Different myositis-specific auto-antibodies have been identified and, on the basis of clinical, histopathological and serological features, IIM can be classified into several subgroups - dermatomyositis (including amyopathic dermatomyositis), antisynthetase syndrome, immune-mediated necrotizing myopathy, inclusion body myositis, polymyositis and overlap myositis. The prognoses, treatment responses and organ manifestations vary among these groups, implicating different pathophysiological mechanisms in each subtype. A deeper understanding of the molecular pathways underlying the pathogenesis and identifying the auto-antigens of the immune reactions in these subgroups is crucial to improving outcomes. New, more homogeneous subgroups defined by auto-antibodies may help define disease mechanisms and will also be important in future clinical trials for the development of targeted therapies and in identifying biomarkers to guide treatment decisions for the individual patient.

Bisphosphonates for the Treatment of Calcinosis Cutis-A Retrospective Single-Center Study

(1) Background: Calcinosis cutis is a frequent symptom of autoimmune connective tissue diseases leading to pain, transcutaneous expulsion of calcified material and bacterial superinfection. There is a high need for new therapeutic options as no standardized treatment algorithm is established. While case reports indicate beneficial effects of bisphosphonates, standardized evaluation of treatment effects is missing. (2) Methods: In this retrospective analysis we evaluate the effects of intravenous pamidronate, a second-generation bisphosphonate, in seven patients with calcinosis cutis using consecutive clinical pictures, radiological examinations and patient’s subjective evaluation. (3) Results: 5/6 patients reported a reduction of pain, improvement of general condition and cessation of calcinosis progression. Regression of skin lesions was detectable in clinical pictures of 2/6 patients, while 1/6 patients had stable disease. Radiological examination revealed improvement or stable disease in 3/5 patients. Fever was the most common side effect. One out of seven patients developed osteonecrosis of the jaw. (4) Conclusions: Bisphosphonates appear to have beneficial effects in a subgroup of calcinosis cutis patients. While patient’s subjective evaluation was mainly positive, objective assessments showed improvement in approximately half of the cases. With regard to potential severe side effects, a careful risk-benefit evaluation is necessary before treatment initiation.

Efficacy of intralesional sodium thiosulfate for the treatment of dystrophic calcinosis cutis: A double-blind, placebo-controlled pilot study

Background

Intralesional injection of sodium thiosulfate has emerged as a promising therapy for calcinosis cutis, but to our knowledge there are no randomized controlled trials evaluating its efficacy as a treatment.

Objective

Conduct a prospective, double-blinded investigation of intralesional sodium thiosulfate versus normal saline in the treatment of dystrophic calcinosis cutis.

Methods

This prospective pilot study injected normal saline or sodium thiosulfate at 0.1 mL/cm² into lesions at baseline and at 1- and 2-month follow-up. Subjects were followed for a total of 12 weeks. An in-person Physician Global Assessment score was assigned by the injecting physician at each visit and was repeated by an independent observer.

Results

Of 4 subjects who completed the study, only 1 experienced improvement in the size and Physician Global Assessment score of the lesion. By 3-month follow-up, there was no difference between the average size of the treatment and control lesions (P = .39).

Limitations

This was a small single-center study with limited demographic diversity and a short follow-up period. Only dystrophic calcinosis cutis subjects were included, and subjects received only 3 monthly injections of sodium thiosulfate.

Conclusions

With only 1 positive response, our results highlight the need for further study of sodium thiosulfate treatment for dystrophic calcinosis.

Calcified leg Ulcers in older patients: clinical description, morphology and chemical characterization

Chronic wounds, including leg ulcers, constitute an important medical problem among older patients. Dystrophic calcifications (DC) are associated with a variety of disorders, including leg ulcers. The aim of this study was to report the clinical and biological characteristics of older patients with DC in leg ulcers and to determine the morphology and chemical composition of these calcifications. We conducted a prospective monocentric study in our Geriatric-Wound and Healing ward, Rothschild Hospital, Paris, from January 2018 to December 2019. Patients with leg ulcers were screened for DC by palpation. Patients' clinical, biological and radiological findings were collected. DC morphology was analyzed using field-emission scanning electron microscopy and chemical composition was analyzed using µFourier transform infra-red spectroscopy and X-ray Fluorescence. Ten (7%) of the 143 patients hospitalized for leg ulcers presented DC. Older patients with DC were more likely to have leg ulcers with venous insufficiency (P=0.015), colonized by Pseudomonas aeruginosa (P=0.026), with a longer healing evolution (P=0.0072) and hypercalcemia (P=0.041). Five DC were extracted from ulcers: two presented 500 nm lacunar spheres and intermingled fibrils of about 10 nm in diameter, consistent with bacterial and biofilm imprints. DC were always composed of Calcium-phosphate apatite and associated to the presence of Zinc. Our analyses were consistent with the involvement of microorganisms and inflammatory process in DC formation. Early management of venous insufficiency, treatment of chronic bacterial colonization and use of calcium-solubilizing drugs seem to be rational strategies for calcified leg ulcer management in older patients.

That's Not Molluscum! A literature review of 109 cases of subepidermal calcified nodules

Subepidermal calcified nodule (SCN) is a rare presentation of idiopathic calcinosis cutis. A literature review was conducted, with 109 cases reported in 268 articles. We report the demographic data, SCN clinical and histological characteristics, common differential diagnoses, and treatments performed from this analysis.

Local, non-systemic, and minimally invasive therapies for calcinosis cutis: a systematic review

Calcinosis cutis is a deposition of calcium in the skin and subcutaneous tissue, often accompanied by pain, reduced mobility, and chronic infections. Limited evidence is available about the feasibility and efficacy of therapies alternative to systemic treatment and surgical excision, both of which often lead to unsatisfactory results or complications. We conducted a systematic review to evaluate the efficacy and safety of topical and intralesional sodium thiosulfate, extracorporeal shock-wave lithotripsy (ESWL), and laser for calcinosis cutis. PubMed, Embase, and Web of Science were searched. Reports of calciphylaxis and treatment combined with systemic medications were excluded. A total of 40 studies including 136 patients were analysed. Partial or complete remission after monotherapy was observed in 64% to 81% of cases. Self-applied topical sodium thiosulfate required patient’s adherence (mean treatment duration, 4.9 months; range 2–24). Laser therapy enabled complete remission of microcalcifications after a single procedure (57%; 12/21). ESWL and intralesional sodium thiosulfate injections decreased calcinosis-associated pain (median reduction in VAS score, 3; range 0–9 and 1; range 0–5, respectively). The most common adverse event was scarring and hyperkeratosis, observed after CO₂ laser (56%; 10/18). Intralesional sodium thiosulfate injections caused transient pain in over 11% of patients. Recurrences within the follow-up were rare (2%; 3/136). This study provides an overview of minimally invasive and local therapies that in selected cases might transcend conventional treatment. The limitation of this study is the poor level of evidence, which emerges mainly from non-randomized studies at high risk of bias.

Understanding calcinosis cutis

Calcinosis cutis is the aberrant deposition of insoluble calcified salts in cutaneous tissue that occurs in association with a variety of diseases. A relatively uncommon disorder, it can range in severity from mild to debilitating. This article describes a patient with a long history of dermatomyositis who developed multiple calcific lesions in the extremities that did not respond to conservative therapies and eventually required multiple surgical interventions.

Treatment of Calcinosis in Juvenile Dermatomyositis

PURPOSE OF REVIEW

Juvenile dermatomyositis (JDM) is a rare autoimmune disease characterised by muscle and skin involvement. Calcinosis is a debilitating complication of JDM which is difficult to treat and may cause long-term morbidity. The purpose of this review is to provide an update for the treatment of JDM-associated calcinosis based on previously published studies.

RECENT FINDINGS

Evidence-based studies are lacking for the management of calcinosis, and current treatment modalities have been largely based on case reports, case series, cohort studies, limited controlled studies and anecdotal clinical experience. The use of early aggressive therapy for resistant cases is strongly suggested to halt persistent disease activity which may help in reducing steroid use and their associated complications. Recent insights into disease pathogenesis, myositis-specific antibodies and genetic associations have led to identification of novel therapeutic targets such as Janus kinase (JAK) 1/2. Different treatment regimens with variable outcomes are in use for the treatment of refractory calcinosis; nevertheless, the level of evidence is not sufficient to propose specific guidelines. Recently, JAK 1/2 inhibitors have shown to be effective as an emerging therapeutic option highlighting that translational and clinical research is crucial to develop targeted treatment for JDM-associated calcinosis.

Clinical and ultrasound response to intralesional sodium thiosulfate for the treatment of calcinosis cutis in the setting of systemic sclerosis. A case-based review

Calcinosis cutis (CC) is defined as the deposition of calcium salts on the skin and subcutaneous tissue. It is associated with different conditions, including some autoimmune diseases, and it can generate significant inflammation, pain, and functional impairment. Different therapies have been tried with limited results. Intralesional sodium thiosulfate seems a promising therapeutic option. We report a patient with diffuse systemic sclerosis who presented with two symmetrical plaques on both axillae, which caused pain and skin retraction. The clinical diagnosis was consistent with CC, which was confirmed by skin biopsy and ultrasound. The patient was treated with a 250 mg/ml solution of sodium thiosulfate injected into the plaques. Complete resolution was achieved after three monthly sessions. The only reported adverse effect was a transient burning sensation during the injections. Given its effectiveness and safety, we believe that intralesional sodium thiosulfate could become a valid first-line option for the treatment of CC.

Idiopatic Auricular Calcinosis Cutis

Calcinosis cutis is a rare disease characterized by the deposition of insoluble calcium phosphate crystals in the epidermis. Etiologically it is divided into 4 types: dystrophic, metastatic, iatrogenic and idiopathic. The most common type is the dystrophic type and the rarest idiopathic type. The pathophysiology of calcinosis cutis is not clearly known. Its definitive diagnosis is made histopathologically by showing calcium accumulation in the skin and clinically excluding other types. A pediatric patient was admitted to our clinic with a left auricular mass, and histopathological findings were diagnosed as idiopathic calcinosis cutis. Our case is presented in the light of literature because it is seen in auricula, an atypical localization of idiopathic calcinosis cutis, which is a rare type.

Scleroderma of the Hand: Evaluation and Treatment

Scleroderma is derived from Latin meaning hard skin. It is an uncommon, noninflammatory connective tissue disorder characterized by increased fibrosis of the skin and in certain variants, multiple other organ systems. Scleroderma involves a spectrum of pathologic changes and anatomic involvement. It can be divided into localized and systemic scleroderma. Hand involvement is common and can include calcium deposits within the soft tissues, digital ischemia, and joint contracture. Nonsurgical management consists of lifestyle modifications, biofeedback, therapy for digital stiffness/contracture, and various pharmacologic medications. When nonsurgical measures are unsuccessful, certain surgical options may be indicated, each with their inherent advantages and pitfalls. Patients with scleroderma who are undergoing surgical intervention pose unique difficulties because of their poorly vascularized tissue and deficient soft-tissue envelopes, thus increasing their susceptibility to wound healing complications and infection. Some subgroups of patients are frequently systemically ill, and specific perioperative measures should be considered to reduce their surgical risk. The spectrum of hand manifestations seen in patients with scleroderma will be reviewed with the focus on evaluation and management.

Severe Iatrogenic Calcinosis Cutis From Extravasated Calcium Gluconate

Iatrogenic calcinosis cutis occurs when insoluble calcium salts deposit in cutaneous and subcutaneous tissue. Iatrogenic calcinosis cutis is a rare complication from a variety of medical interventions, most commonly due to extravasated intravenous calcium-containing solutions. We present a severe case of iatrogenic calcinosis cutis in a patient with end-stage renal disease and an elevated serum calcium-phosphate product. Iatrogenic calcinosis cutis has a wide range of clinical presentations. Either subclinical or clinically noticeable extravasations may cause mild to severe calcinosis cutis. Patients with increased serum calcium and phosphate may be at increased risk of iatrogenic calcinosis cutis. Treatment options include conservative, pharmacologic, or surgical management.

MR imaging findings of calcinosis cutis in primary Sjogren syndrome, a rare manifestation

Soft tissue calcifications associated with various connective tissue diseases such as dermatomyositis and scleroderma have been well documented Plaque-like sheets of subcutaneous calcifications presenting as an indurated soft tissue mass in a patient with primary Sjogren syndrome have been rarely documented in the literature. We present the magnetic resonance and conventional radiographic findings of calcinosis cutis and calcinosis circumscripta of a 47-year-old woman with biopsy proven Sjogren syndrome. We also delineate various types of soft tissue calcification, histopathology of calcinosis cutis, and current treatment options. Recognizing the magnetic resonance characteristics of this phenomenon may prove useful to radiologists, especially in the absence of clinical history and conventional radiographs.

Delayed septic radiation-induced calcinosis cutis long after cured anorectal cancer

PURPOSE

Calcinosis cutis is an anecdotal local injury seen long after irradiation in cancer survivors. Our purpose was to shed light on this little studied and potentially serious ulceration.

CASES

We report two cases of severe perineal-sacral infection with hard lesions, one decade after anorectal cancer irradiation. CT-scans showed extensive calcification and soft tissue inflammation, but previous radiation therapy was overlooked and the diagnosis was not made for several months after various tests, including biopsy. The two patients had different comorbidities and were managed by multidisciplinary collaboration between specialists. Surgery of the sacral ulcer was limited by the accessibility of non-irradiated tissues. In the absence of current guidelines, after radiopathological expertise, we used a "draining" procedure followed by antifibrotic pentoxifylline-tocopherol-clodronate treatment.

CONCLUSION

Long after pelvic radiotherapy, symptomatic subcutaneous macrocalcification is suggestive of radiation-induced calcinosis. Prolonged antibiotic therapy followed by PENTOCLO treatment led to clinical improvement.

Epidemiology and Treatment of Calcinosis Cutis: 13 Years of Experience

Background:

Calcinosis cutis is a rare condition associated with different diseases, which is difficult to manage.

Aims and Objectives:

In this retrospective study, the epidemiology of calcinosis cutis and the effectiveness of various treatment regimens in its management were assessed in a single center.

Materials and Methods:

The data of 34 patients suffering from calcinosis cutis (male:female = 12:22; mean age = 48.6 ± 18.6 years) treated at our department between 2003 and 2016 were analyzed retrospectively.

Results:

Dystrophic, idiopathic, metastatic subtype, and calciphylaxis occurred in 70.6%, 11.8%, 5.9%, and 11.8% of the cases, respectively. Underlying diseases of dystrophic calcinosis included autoimmune connective tissue disease, skin trauma, cutaneous neoplasm, and inherited disorder in 58.3%, 20.8%, 12.5%, and 8.3% of the cases, respectively. Extremities were most frequently affected (n = 18). In the management, diltiazem was most frequently used in monotherapy with partial response in five of eight cases. Other drugs in monotherapy or in combination were administered in single cases. Surgical treatment resulted in least partial response in all of the cases followed (n = 7).

Conclusion:

Dystrophic was the most common subtype and autoimmune connective tissue disease was the most frequent underlying disease. We conclude that lower doses of diltiazem have only partial efficiency, and surgical therapy is at least partially effective in localized calcinosis.

Dystrophic calcinosis cutis in autosomal recessive dystrophic epidermolysis bullosa

A 6-year-old girl presented with a history of blistering and scarring in trauma-prone areas. On examination, calcium deposits were seen on bilateral palms and soles within her non-healing wounds. Clinical, genetic and radiological evaluation confirmed the diagnosis of autosomal recessive dystrophic epidermolysis bullosa with dystrophic calcification. The patient was started on topical 10% sodium thiosulfate for her calcinosis cutis. Identification and management of dystrophic calcification are important as it impairs wound healing.

Miscellaneous Perianal Afflictions

This article provides an overview of hidradenitis suppurativa, lichen planus, lichen sclerosis, calcinosis cuti, pyogenic granuloma, intertrigo, and seborrheic keratosis. This article also focuses on recognition and management of these pleomorphic afflictions of the perianal region.

Dermatomyositis: Diagnosis and treatment

The second article in this continuing medical education series reviews the initial evaluation of patients with suspected dermatomyositis (DM), the relevant work-up for malignancy and interstitial lung disease once a diagnosis of DM is made, and treatment recommendations for patients with DM based on disease severity, the presence of systemic symptoms, and myositis-specific antibody (MSA) profiles. This review emphasizes the emerging role of MSAs in the diagnosis of DM and highlights how MSAs can be used to guide the appropriate work-up for malignancy and interstitial lung disease. The treatment approach proposed by this continuing medical education series discusses both established and novel therapies for DM and highlights the importance of considering lesion type, degree of muscle involvement, presence of systemic symptoms, presence of MSAs, and patient age when determining the best treatment approach for a patient with DM.

Topical sodium thiosulfate for calcinosis cutis associated with autoimmune connective tissue diseases: the Mayo Clinic experience, 2012-2017

In this case series, we retrospectively identified all patients treated with topical sodium thiosulfate (TST) for calcinosis cutis (CC) associated with underlying autoimmune connective tissue diseases at Mayo Clinic (Rochester, MN, USA) during the period 1 January 2012 to 27 June 2017. Of 28 patients identified (mean age 57.0 years; 96% female), 19 (68%) had clinical improvement of their CC with TST, 7 (25%) had no response and 2 (7%) had unknown response. There were adverse events in three patients: two had skin irritation and the third, who had a zinc allergy, experienced pain with application. Overall, our findings support those of previous case reports that TST appears to be a relatively well-tolerated adjuvant treatment for CC, although future studies with a control group are warranted to assess the true efficacy of TST for the indication of CC.

Lacrimal punctal and peripunctal involvement in calcinosis cutis

Calcinosis cutis is a rare metabolic disorder characterized by cutaneous and subcutaneous deposition of insoluble calcium salts. Ocular adnexal involvement is uncommon but mostly seen in males and in the upper eyelid. Solitary lesions are more common than multiple. The treatment of choice is excision biopsy. Histopathological examination provides a definitive diagnosis. Directed systemic investigations help to rule out underlying pathologies and aids further management. The present case reports the punctal and peripunctal involvement in a case of ocular adnexal calcinosis cutis.

Lack of response to intravenous sodium thiosulfate in three cases of extensive connective tissue disease-associated calcinosis cutis

Dystrophic calcinosis cutis is a debilitating condition of calcium salt deposition in the skin often occurring in association with connective tissue disease (CTD). Available treatments for calcinosis cutis are unsatisfactory, but given the recent use of topical and intralesional sodium thiosulfate (STS) to treat calcifying disorders, we sought to describe the use of intravenous (IV) STS for CTD-associated dystrophic calcinosis cutis. We report three patients with long-standing and extensive CTD-associated calcinosis cutis treated with IV STS after having failed multiple prior therapies. All three patients experienced fatigue and nausea with STS infusions, and none of the patients had notable clinical or symptomatic improvement of calcinosis. It remains to be seen whether the administration of IV STS earlier in the onset of calcinosis might be of benefit given that these patients all had long-standing and refractory CTD-associated calcinosis. Given the small number of patients in this series, further investigation into the use of IV STS in calcinosis cutis is warranted.