A 66-year-old woman with a history of scleroderma presents to the clinic. Currently, she has cutaneous calcium deposits on the left forearm with ulceration and sinus tracts, which have been present for the past month. The skin is very painful to the touch and sore at rest.
This case has been brought to you in partnership with the Journal of Orthopedics for Physician Assistants.
Submit your diagnosis to see full explanation.
Scleroderma and CREST (calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome are connective tissue disorders that frequently include the presence of cutaneous nodules and plaques of calcium deposits. These calcium lesions can be a few millimeters to a few centimeters in size and frequently occur in the upper extremities (most commonly on the hands). The calcium lesions can be painful and may exude a chalky material, form sinuses, ulcerate, and/or become chronically infected. Deposition of calcium into soft tissue occurs in 25% of those with systemic sclerosis.1
A diet low in calcium and the administration of phosphate with aluminum hydroxide can improve or halt disease. Minocycline is often used as a first-line treatment for patients with painful, ulcerating dermal calcinosis. The drug has calcium-chelating properties and is thought to reduce inflammation and ulceration associated with calcium deposits. Patients often must take minocycline for years because the calcinosis nearly always returns shortly after the medication is discontinued.
Minocycline is also prescribed cyclically for 4 to 6 weeks, which can control the calcinosis for 3 to 4 months before the medication must be started again. Other treatments include warfarin, colchicine, bisphosphonates, diltiazem, intralesional steroid injections, extracorporeal shock wave lithotripsy, and carbon dioxide laser therapy. Surgical excision is occasionally used to remove ulcers, sinus tracts, or chronic infections. Of all the treatments, minocycline is the least invasive and the best tolerated. Because the cause of cutaneous calcium deposits is still unknown, the condition is very difficult to treat. The success rate for all types of treatment is variable, and the recurrence rate is high despite treatment.2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Walsh JS, Fairley JA. Calcifying disorders of the skin. J Am Acad Dermatol. 1995;33:693-706.
- Robertson LP, Marshall RW, Hickling P. Treatment of cutaneous calcinosis in limited systemic sclerosis with minocycline. Ann Rheum Dis. 2003;62:267-269.