Published on 19/03/2015 by admin
Filed under Dermatology
Last modified 19/03/2015
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Rajani Nalluri and Ian Coulson
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Calcinosis cutis is a rare disease of aberrant calcium deposition in the skin and subcutaneous tissue. There are four major types:
Idiopathic: occurs without tissue injury or metabolic defect (e.g., idiopathic scrotal calcinosis).
Dystrophic: secondary to local tissue damage or alterations in collagen, elastin or subcutaneous fat but normal calcium and phosphate levels (e.g., in connective tissue diseases, post trauma or infection).
Metastatic: abnormal calcium and/or phosphate metabolism leading to precipitation of calcium salts in normal tissue.
Iatrogenic: secondary to a treatment or procedure (such as extravasation of calcium or phosphate infusions).
Other rare variants of calcinosis cutis that have been described include calcinosis cutis circumscripta, calcinosis universalis, tumoral calcinosis, transplant-associated calcinosis cutis, and milia-like idiopathic calcinosis cutis (usually associated with Down syndrome). Firm white or yellow dermal lesions may ulcerate and extrude a gritty material. Stiffening of the skin can limit joint mobility and function, and fingertip lesions may be painful.
The first step in management is to identify any underlying cause. Dystrophic calcification occurs in up to 10% of patients with scleroderma and 10–40% of patients with juvenile dermatomyositis, but is rare in systemic lupus erythematosus. Examination and investigations for connective tissue disease are therefore strongly recommended. Skin biopsy can help to distinguish cutaneous calcification from ossification.
A number of malignancies have been implicated in causing metastatic calcification (e.g., leukemia and multiple myeloma). However, successful treatment of the underlying cause does not always have an impact on calcinosis cutis, which frequently requires other treatment modalities. There are no large studies for the treatment of calcinosis cutis, and most therapies are based on case reports.
Spontaneous extrusion of calcium salts may occur; this may need surgical encouragement. Intralesional corticosteroids, aluminum hydroxide supplements, bisphosphonates, diltiazem, colchicine, and probenecid have shown success, mostly in calcinosis associated with dermatomyositis. Low-dose minocycline has been reported to reduce the frequency of ulceration and inflammation associated with cutaneous calcinosis in patients with limited systemic sclerosis. The mechanism of action may be mainly through inhibition of matrix metalloproteinases and anti-inflammatory effects.
Warfarin has been advocated in both dermatomyositis and systemic sclerosis-associated calcinosis for small calcified deposits. Carbon-dioxide laser vaporization, extracorporeal shock wave lithotripsy and intravenous immunoglobulin are recent approaches that have been tried in cutaneous calcinosis secondary to CREST syndrome.
Full blood count
Urea and creatinine
Serum calcium and phosphate
Parathyroid hormone levels
Vitamin D levels
Serum electrophoresis
Creatine kinase
Autoantibodies
Skin biopsy
Plain radiographs
Bone scintigraphy
Pitt AE, Ethington JE, Troy JL. Cutis 1990; 45: 28–32.
A case of dystrophic calcinosis following trauma that resolved over 8 weeks with spontaneous transepidermal elimination.
Park YM, Lee SJ, Kang H, Cho SH. J Korean Med Sci 1999; 14: 589–92.
A 22-year-old woman with systemic lupus erythematosus developed soft tissue calcification with ulceration, infection, and abscess formation. She was treated with aluminum hydroxide 600 mg three times a day with reduction in size and softening of the deposits after 9 months.
Nakagawa T, Takaiwa T. J Dermatol 1993; 20: 558–60.
A case of calcinosis cutis in juvenile dermatomyositis was successfully treated with oral aluminum hydroxide; near complete clearance was observed after 8 months of therapy.
Treatment of Skin Disease Comprehensive Therapeutic Strategies 4e
No treatment/self-healing
Aluminum hydroxide
Intralesional corticosteroid
Diltiazem
