Surgical Debulking for Symptomatic Management of Calcinosis Cutis of the Hand and Upper Extremity in Systemic Sclerosis

Calcinosis in systemic sclerosis: An update on pathogenesis, related complications, and management: A heavy burden still waiting to be lifted off patients' hands

In SSc, dystrophic calcinosis is one of the major clinical manifestations, characterized by the deposition of insoluble calcific substances in tissues, predominantly in the chemical form of calcium hydroxyapatite. Furthermore, calcinosis might lead to compressive neuropathies and severe pain. Current evidence suggests that tissue ischemia and repeated trauma are implicated in the development of calcinosis; however, there are still too many unknown areas that need to be investigated. Detection of calcinosis is commonly performed using X-ray or ultrasound. Moreover, quantification of calcinosis with X-ray and dual-energy computed tomography might be useful for the assessment of disease burden and monitoring of the disease. Despite its prevalence and clinical outcomes, there are no approved disease-modifying treatments for calcinosis in SSc. Debulking or surgical intervention might be preferred for calcinosis complicated with infection, compressive symptoms, or relief of pain. Therefore, innovative investigations and tailored therapeutic approaches are urgently needed to lift the burden of calcinosis from the hands of SSc patients.

Expanding the Treatment Team

The optimal systemic sclerosis (SSc) care plan includes an occupational therapist and physical therapist as well as wound care experts and a registered dietitian if indicated. Screening instruments for functional and work disability, hand and mouth limitations, malnutrition, and dietary intake can identify the need for ancillary support services. Telemedicine can assist in developing effective ancillary treatment plans. Reimbursement for services may limit access for patients with SSc to expand their care team but a focus on prevention rather than management of damage is recognized as an important unmet need in SSc. In this review, the role of a comprehensive care team for SSc is discussed.

Idiopathic calcinosis cutis causing cubital tunnel syndrome: A case report and review of literature

Calcinosis cutis is a type of heterotopic calcification where abnormal calcium deposition occurs in skin or subcutaneous tissue. Among the subtypes of calcinosis cutis, the idiopathic variety occurs without underlying biochemical calcium abnormality. We report a rare case of idiopathic calcinosis cutis causing cubital tunnel syndrome. A 63-year-old female presented with pain and numbness in the ulnar aspect of her left hand. The X-ray of the left elbow showed deposition of radiopaque material on the posteromedial aspect. Her nerve conduction study showed evidence of ulnar nerve compression at the elbow supporting the diagnosis of ulnar nerve compression by the mass of calcium deposition. Surgical exploration was performed, and significant ulnar nerve compression was noted due to the mass effect of the calcium deposition. Excision of the mass and ulnar nerve decompression with anterior transposition was performed with satisfactory outcomes. Although calcinosis cutis causing cubital tunnel syndrome has been previously reported, all patients had some form of calcium dysregulation. We report the first case of ulnar nerve compression at the cubital tunnel due to idiopathic calcinosis cutis. Excision of the mass and ulnar nerve decompression with anterior transposition was successful in our patient despite the incomplete excision of the calcium deposition.