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Painful fingertip calcinosis cutis causes substantial morbidity in patients with CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia), also called limited cutaneous scleroderma. Medical therapy for this condition is uniformly disappointing.
A 58-year-old man with CREST syndrome for the past 20 years presented with a 3-week history of a painful digital hyperkeratotic plaque on the tip of his left hand’s third finger (Figure 1A and Figure 2). Medical treatments, including nifedipine, colchicine, pentoxifylline, and baby aspirin, failed to produce significant pain reduction. Radiographs showed fingertip calcium deposits consistent with calcinosis cutis.
Clinical photographs of our subject patient. A, Painful keratotic plaque on the tip of the left hand’s third finger. B, Calcium in the deep dermis exposed after removal of the callus. C, Healed wound after 4 months.
In this radiograph of our subject patient, a lobulated, 4 × 4-mm calcific density is plainly visible at the tip of the distal phalanx of the left hand’s third finger.
A surgical approach to the calcinosis cutis resulted in complete pain resolution. After a digital block, a No. 15 blade was used to remove the callus overlying the calcinosis. Calcium was then exposed (Figure 1B) and removed using a 2-mm curette. Postoperative wound care consisted of petroleum jelly and a new nonstick bandage applied daily. Removal of the calcium deposit was followed by immediate pain relief, and the patient was comfortable during and after the healing process (Figure 1C). Seven months after the procedure, the plaque did not recur, and he continued to be pain free.
Dystrophic calcification is the most common cause of calcinosis cutis.1 It is estimated that approximately 40% of people with CREST syndrome will develop calcium deposits in the hand.2 Calcinosis is more likely to occur in patients with disease of greater than 10 years' duration, more severe Raynaud phenomenon, and frequent digital necrosis.3 The most common location for hand calcification is on the volar side of the distal phalanges.3
Unfortunately, the medical treatment of calcinosis is disappointing. Various medications, including warfarin, colchicine, probenecid, bisphosphonates, diltiazem, minocycline, and intralesional corticosteroids have been used to treat calcinosis.4
Surgical excision of areas of painful calcinosis is often necessary for pain reduction. Reported surgical treatments include a high-speed micropoint dental burr3 and carbon dioxide laser.5 Most patients with systemic sclerosis will have blood vessel wall thickening and luminal narrowing due to connective tissue matrix deposition with superimposed Raynaud phenomenon, thus increasing the risk for potential postoperative digital ischemia, slow wound healing, skin necrosis, and impaired range of motion. However, in the largest published series (of 272 hand operations in 70 patients with systemic sclerosis), wound healing was reported to be uncomplicated in all procedures.3
We propose curettage as the primary treatment of localized painful fingertip calcinosis cutis. Curettage preceded by digital or local nerve block can be performed with a small curette or an ear curette. The procedure debulks the calcium deposit but does not usually remove the entire deposit. Healing occurs despite residual calcium. Pain relief usually follows the procedure. This technique results in excellent clinical outcomes, including decreased pain and usually short healing times.
Correspondence: Dr J. Miller, Department of Dermatology, Penn State Milton S. Hershey Medical Center, 500 University Drive, HU14, Hershey, PA 17033 (jmiller4@hmc.psu.edu).
Financial Disclosure: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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