A Novel Treatment for Ulcerative Calcinosis Cutis

September 2011 | Volume 10 | Issue 9 | Original Article | 1042 | Copyright © 2011

Brooke Bair DO and David Fivenson MD

Abstract

Background: Calcinosis cutis is a term used to describe a group of disorders which result in calcium deposits in the skin. These disorders can be separated based on etiology.
Objective and Methods: Sodium thiosulfate has been used to systemically treat calciphylaxis with little to no adverse effects. We report two cases of ulcerative calcinosis cutis which were refractory to multiple topical treatments and did not improve with correction of underlying electrolyte abnormalities.
Results: Both cases showed an excellent response to topical 25% sodium thiosulfate compounded in zinc oxide.
Limitations: We are limited by a small sample size (n=2) in this case series.
Conclusions:We recommend topical sodium thiosulfate 25% as an alternative treatment for dystrophic calcinosis cutis.

J Drugs Dermatol. 2011;10(9):1042-1044.

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INTRODUCTION

Originally described by Virchow in 1855, calcinosis cutis is a term used to describe a group of disorders in which calcium deposits form in the skin. This condition is classified into four major types according to etiology: dystrophic, metastatic, iatrogenic and idiopathic.1 Sodium thiosulfate has been used to systemically to treat calciphylaxis with good results.2 We report two cases of refractory calcinosis cutis successfully treated with topical 25% compound of sodium thiosulfate.

Case Reports

Case 1
A 74-year-old female with a past medical history of multiple sclerosis and osteoarthritis presented complaining of a non-healing ulcer on the right lower leg which had previously failed multiple treatments, including compressive dressings with xenograft (Oasis) and allogeneic bilayered graft (Apligraf). Physical examination revealed bilateral 2-3+ pitting edema. The right distal lower extremity showed an ulcer measuring 38x13x2 mm with a few discrete white-yellow firm papules toward the periphery (Figure 1).

Histopathology showed cutaneous calcium deposition with surrounding fibrosis. Laboratory examination revealed pseudohypoparathyroidism—vitamin D level was low (8 ng/ml, normal >30 ng/ml),3 and parathyroid hormone was elevated (200.1 pg/ml, normal 12.0-88.0 pg/ml).3 A parathyroid ultrasound was normal. The parameters were corrected with vitamin D supplements with no effect on healing after three months. Normal laboratory values included serum calcium, phosphate, CBC and metabolic profile. Wound cultures were negative.

The patient was started on topical sodium thiosulfate 100% powder mixed 1:4 (25%) in zinc oxide applied twice-daily to the wound base and periwound skin with elastic wraps for compression and leg elevation. The wound showed marked improvement after five weeks with good re-epithelialization (Figure 2). She completely healed after 15 weeks of continued therapy (Figure 3).

Case 2
An 81-year-old male with an unremarkable past medical history presented complaining of a pruritic "scaly eruption" on both lower legs for years after sustaining second- and third-degree burn injuries. He had previously failed compressive dressing treatments with topical steroids, topical paraffin emulsion, silver sulfasalazine, triple-antibiotic ointment and Oasis.

Physical exam of the left lower leg revealed a tender, macerated, fibrous, centrally calcified ulcer measuring 15x10x3 mm (Figure 4). Laboratory examination revealed elevated serum calcium—9.8 mg/dL (normal=4.4–5.3 mg/dL)3 and mild renal insufficiency (creatinine—1.9, normal=0.8 to 1.4 mg/dL).3 Albumin, parathyroid hormone and vitamin D levels were within

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