Extracorporeal shockwave lithotripsy- a ray of hope in dystrophic calcinosis cutis treatment

Dystrophic calcinosis cutis (DCC) is a chronic disorder of calcium deposition in the skin and subcutaneous tissues seen in association with scleroderma or dermatomyositis. it is a debilitating condition often presenting with intractable pain or persistent ulceration. Treatment outcomes have been disappointing and thus most of the treatments aim at limiting morbidity.

Usually the treatment of calcinosis cutis is initiated with an oral agent used for its anti-inflammatory or calcium-binding properties like minocycline, diltiazem or colchicine. Bisphosphonates have also been used to obliterate macrophages in calcium deposits leading to inhibition of cytokine activation. Role of intralesional corticosteroids and sodium thiosulfate is limited in extensive deposits. Surgical excision or debulking carries the risk of poor wound healing and persistent ulceration.

ESWL is an accepted treatment for urolithiasis, using shock waves to fragment calcium deposits in the urinary tract. The underlying principle is that an acoustic wave is transmitted to a calcium deposit, with resulting reverberations causing fragmentation of the calcification. Using this concept extracorporeal shockwave lithotripsy (ESWL) has gained importance in the treatment of DCC and a case report highlighting the use of this modality was published in the Clinical and Experimental Dermatology journal.

A 72-year-old woman with limited scleroderma presented with a 2-year history of a painful, linear plaque involving the volar aspect of her left forearm. A clinical diagnosis of DCC was made and confirmed by magnetic resonance imaging. The patient was started on rifampicin and clindamycin but the ulceration progressed despite treatment. Treatment with tetralysal, diltiazem and an oral bisphosphonate were tried without significant clinical improvement.

Then the treating the patient was treated with 1200 shocks of ESWL on three occasions leading to fragmentation of the calcium deposit followed by extrusion from the skin and subcutaneous tissues over subsequent weeks. Following three courses of treatment, there was complete closure of the sinus tract on the left arm and only minimal residual burden of calcinosis remained.

This case report brings to light that ESWL can be a very successful non-invasive and safe option in the treatment of DCC leading to decreased morbidity and faster clearance.

Source- Beatty P, Killion L, Power R, Roche M. Dystrophic calcinosis cutis successfully treated with extracorporeal shockwave lithotripsy. Clin Exp Dermatol. 2021 Sep 9.