Calcinosis Cutis
 insoluble compounds of calcium are deposited within the skin due to local and/or
systemic factor (mainly calcium hydroxyapatite or amorphous calcium phosphate
Classification
1. Dystrophic calcification
o calcium deposits in the soft tissues but have no generalized disturbance
in calcium or phosphorus metabolism
o often seen at sites of previous inflammation or damage to the skin or
may occur in association with connective tissue disease, such as in
systemic sclerosis (scleroderma) or polymyositis-dermatomyositis.
o May go on to ossify – heterotrophic ossification
o Causes (VINDICATE – surgical sieve):
1. Vascular – venous insufficiency
2. Infective – parasitic
3. Neoplasm
o Pilomatrixoma, or calcifying epithelioma of Malherbe, is the
most common tumor that becomes calcified.
4. Drugs – vitamin D
5. Iatrogenic
6. Congenital
7. Autoimmune – scleroderma
8. Trauma – burns, insect bites, injection granuloma
9. Ediopathic
2. Metastatic calcification
o Calcification occurring as the result of systemic hypercalcemic or
hyperphosphatemic states (renal failure, hyperparathyroidism,
sarcoidosis, paraneoplastic syndrome)
3. Idiopathic - occurs in the absence of known tissue injury or systemic
metabolic defect
o Idiopathic calcinosis of scrotum, penis, or vulva:
o Tumoral calcinosis: This may be caused by an error in renal
phosphate metabolism resulting in hyperphosphatemia. General
characteristics of the calcified nodules are a large size, a juxta-articular
location, progressive enlargement, a tendency to recur after surgical
removal, and the ability to encase the adjacent normal structures.
o Calcinosis cutis circumscripta and calcinosis universalis: These forms
are rare and may be due to altered ground substances. Calcinosis cutis
circumscripta generally occurs earlier and tends to involve the
extremities, whereas calcinosis universalis occurs later and is usually
more widespread.
o Transplant-associated calcinosis cutis
4. Iatrogenic
o Parenteral administration of calcium or phosphate:
o Tumor lysis syndrome
o Repeated heel sticks in the newborn
Investigations
1. Blood tests
a. Ca, ALP, phosphate, albumin
b. Urea/Cr
c. Bicarbonate – milk-alkali syndrome in metabolic alkalosis
d. SCL-70 in scleroderma (poor prognosis)
2. Xrays
Treatment
Nonsurgical
1. correct underlying problem
2. Intralesional corticosteroids may be beneficial because of their antiinflammatory and inhibitory effects on fibroblast activity.
Surgical
Indications for surgical removal
1. pain
2. recurrent infection
3. ulceration
4. Functional impairment.
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Because surgical trauma may stimulate calcification, initially treat a test site
before pursuing a large excision.
Recurrence is common after excision.
Electric shock wave lithotripsy was successful in 1 case of dermatomyositisinduced tissue calcification.
Calcium Pyrophosphate Deposition Disease
 arthritis caused by the deposition of calcium pyrophosphate crystals.
 Types
1. pseudogout
2. chondrocalcinosis - calcification within fibrous or hyaline cartilage structures
Pathophysiology
 inflammatory cascade response to the deposition of calcium pyrophosphate
crystals.
 Enzyme or saturation abnormalities allow the formation of excess pyrophosphate,
which "salts out," especially in hyaline and fibrous cartilage. Individuals with
CPDD may have more than 1 type of crystal present (eg, hydroxyapatite in
addition to pyrophosphate).
Heterotopic ossification
 defined as the formation of mature lamellar bone in soft tissues. The process
involves true osteoblastic activity and bone formation
 3 categories of HO have been described:
1. Myositis ossificans progressiva is a rare metabolic bone disease in children with
progressive metamorphosis of skeletal muscle to bone and is characterized by an
autosomal dominant pattern of genetic transmission.
2. Myositis ossificans circumscripta without trauma is a localized soft tissue
ossification after neurologic injury or burns. This process also is referred to as
neurogenic HO.
3. Traumatic myositis ossificans occurs from direct injury to the muscles. Fibrous,
cartilaginous, and osseous tissues near bone are affected. The muscle may not be
involved.
Pathogenesis
 basic defect in HO is the inappropriate differentiation of fibroblasts to boneforming cells. Early edema of connective tissue proceeds to tissue with foci of
calcification and then to maturation of calcification and ossification.
Investigations
 Many clinicians rely on early detection of HO using triple-phase bone scan
technology.
Patient with dystrophic calcification in the Achilles tendon due to recurrent
trauma and tendinitis.
Patient with multiple "rice-grain" calcifications in muscles about knees due to
cysticercosis
66 year old male with scleroderma, exhibiting acroosteolysis, skin atrophy over
fingertips and calcinosis cutis.
Heterotopic ossificiation after head injury
Elderly female with tumoral calcinosis about hand and wrist.
Beware primary bone forming tumor – like this osteosarcoma above