Dermatology Online Journal

Videodermatoscopy: a useful tool for diagnosing cutaneous dystrophic calcifications
Renata Strumia
Dermatology Online Journal 11 (1): 28

Dermatology Unit, Azienda Ospedaliera Universitaria, Arcispedale S. Anna, Ferrara, Italy. restrumi@tin.it

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Abstract

A suspected diagnosis of cutaneous calcification is based on the presence of slightly elevated or ulcerated firm, white papules and plaques; these lesions often extrude white, chalky material. In clinical practice, however, a biopsy is required to confirm clinical suspicions. We attempted to demonstrate cutaneous calcinosis in vivo by using Raman spectroscopy, a nondestructive analytical method based on the analysis of light scattered from the investigated material. We used digital videodermatoscopy to improve the detection of cutaneous calcifications in vivo in two patients with CREST syndrome. A characteristic flower-like arrangement was observed at ×-50 magnification. We believe this pattern may be highly indicative of cutaneous dystrophic calcinosis.

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Introduction

Dystrophic calcification (DC), the most common form of calcinosis cutis, occurs in diseased or previously damaged tissue. DC occurs in localized or generalized types, without visceral involvement or serum calcium and phosphorus abnormalities. The pathogenesis is not well understood, but it apparently involves abnormally high mitochondrial calcium-phosphate levels, resulting in crystal deposition and cell death [1]. Lesions begin as a calcium-phosphate nidus and progress to hydroxyapatite crystal formation within a collagen matrix. In spite of the many technical difficulties, the ultrastructural morphology of calcinosis cutis has been described. One case of dystrophic calcinosis cutis revealed mineralization of elastic fibers [2], whereas another showed mineralization of both collagen and elastic fibers [3]. Pleomorphic-hydroxyapatite crystals were arranged around thick type-I collagen fibrils in a flowerlike arrangement. Elastic fibers appeared speckled from the deposition of star-shaped crystals around the microfibrils. The excessively mineralized fibers were filled with needle-shaped crystals. The ground substance did not contain crystals, but displayed a reticulate or globular structure at the periphery of the calcified material [2].

Localized-dystrophic calcinosis occurs in many inflammatory lesions such as acne, stasis ulcers, and granulomas, as well as benign and malignant neoplasms. Calcinosis circumscripta usually presents as small deposits around the fingers or elbows in patients with scleroderma, or more commonly, CREST syndrome. The deposits may ulcerate and the lesions extrude a thick, white granular material. Calcinosis circumscripta is also reported in patients with systemic lupus erythematosus.

The diagnosis of cutaneous calcification is based on the presence of typical lesions, slightly elevated or ulcerated, firm, white papules and plaques that often extrude white, chalky material. Biopsy is required to confirm the diagnosis. We used digital videodermatoscopy (DVD) to improve the detection of cutaneous calcifications in vivo in two patients with CREST syndrome.

Case reports and results

Figure 1	Figure 2
Fig. 1. Small round cavity filled with amorphous whitish material (× 25 magnification)
Fig. 2. Flower-like arrangement of the calcific material (× 50 magnification)

Two patients affected by CREST syndrome, a 35-year-old woman and a 42-year-old woman, were referred to us. Small, painless, white, ulcerated nodules were present on their elbows and fingers. A Pico Scopeman apparatus was used to perform DVD of the lesions (× 25-100). At ×-25 magnification a small round cavity filled with amorphous white material was observed (Fig. 1). At ×-50 magnification a flowerlike arrangement of the calcific material was revealed (Fig. 2).

Conclusion

The CREST syndrome consists of calcinosis cutis (usually seen on the hands or elbows), Raynaud phenomenon, esophageal disorders, sclerodactyly, and telangiectasia [4]. A diagnosis is based on the presence of at least two of these five signs. For patients who have only one other major feature, confirming the presence of calcinosis is important for the diagnosis.

Cutaneous calcinosis has been studied in vivo using Raman spectroscopy, a nondestructive method of evaluation based on the analysis of light scatter. This tool is used to study the molecular structure of proteins and lipids of the skin, and the diffusion and metabolism of drugs. Gniadecka et al. [5] demonstrate that tophi and skin calcifications produce distinctive Raman spectra, findings that serve as a theoretical basis for a noninvasive diagnostic procedure to confirm the presence of cutaneous calcifications.

To the best of our knoweledge, DVD has not yet been employed to study these lesions. In our patients a flowerlike arrangement is detected with DVD at ×-50 magnification. We believe that this pattern is indicative of cutaneous dystrophic calcinosis.

References

1. Walsh JS, Fairley JA. Calcifying disorders of the skin. J Am Acad Dermatol. 1995;33:693-706. PubMed

2. Fartasch M, Haneke E, Hornstein OP. Mineralization of collagen and elastic fibers in superficial dystrophic cutaneous calcification: an ultrastructural study. Dermatologica. 1990;181:187-92. PubMed

3. Nielson AO, Johnson E, Hentzer B, Kobayasi T. Dermatomyositis with universal calcinosis: a histopathological and electron optic study. J Cutan Pathol. 1979 Dec;6(6):486-91. PubMed

4. Winterbauer RH. Bull. Johns Hopkins Hosp. 1964 Jun;114: 361-383. PubMed

5. Gniadecka M, Wulf HC, Johansson CK, Ullman S, Halberg P, Rossen K. Cutaneous tophi and calcinosis diagnosed in vivo by Raman spectroscopy. Letter. British J Dermatol. 2001 Oct; 145(4): 672-4. PubMed

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