eMedicine Specialties > Dermatology > Metabolic Diseases

Calcinosis Cutis: Differential Diagnoses & Workup

Author: Julia R Nunley, MD, Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center
Coauthor(s): Lydia M E Jones, MD, Staff Physician, Department of Dermatology, Virginia Commonwealth University
Contributor Information and Disclosures

Updated: Jan 27, 2009

Differential Diagnoses

Milia
Molluscum Contagiosum
Mycetoma
Osteoma Cutis
Warts, Genital
Xanthomas

Other Problems to Be Considered

Gouty tophi
Progressive osseous hyperplasia
Subcutaneous cholesterol crystals

Workup

Laboratory Studies

  • Tests of serum calcium, inorganic phosphate, alkaline phosphatase, and albumin levels may be helpful.
    • An elevation in serum calcium and alkaline phosphatase levels with a decrease in the inorganic phosphate level is suggestive of hyperparathyroidism.
    • One can further calculate the calcium-phosphate product to determine if the threshold of 70 mg2/dL2 is exceeded.
    • An albumin value is needed to interpret the significance of hypocalcemia or hypercalcemia. Calcium is highly protein bound, and abnormalities in the albumin concentration may cause clinically insignificant abnormalities of calcium concentration.
  • Serum blood urea nitrogen and creatinine concentrations can be obtained to measure renal function.
  • On the complete blood cell count with differential, hematologic abnormalities may suggest an underlying malignancy or lupus erythematosus.
  • If milk-alkali is suspected, the plasma bicarbonate or arterial pH value may indicate the presence of a metabolic alkalosis.
  • The parathyroid hormone concentration is a direct measurement for hyperparathyroidism.
  • Creatine kinase and aldolase value may be significantly abnormal in cases of dermatomyositis, myositis, or rhabdomyolysis.
  • Serum amylase or lipase levels are markers of pancreatic disease.
  • Antinuclear antibody testing is helpful in screening for lupus erythematosus.
  • In patients with scleroderma, the presence of SCL-70 (topoisomerase) antibody portends a poor prognosis.
  • Vitamin D levels should be determined to evaluate the possibility of vitamin D excess or deficiency.15
  • A test of the 24–hour urinary excretion of calcium and/or inorganic phosphate may be useful.

Imaging Studies

  • Radiographic examination may demonstrate the extent of tissue calcification.
  • Bone scintigraphy with radiolabeled phosphate compounds (technetium Tc 99m methylene diphosphonate [MDP]) is useful in evaluating nonvisceral soft tissue calcification; this test is more sensitive than plain radiography.16,17
  • CT allows for the identification of visceral and nonvisceral calcification. CT is infrequently used in evaluating calcinosis cutis and primarily used in assessing tumoral calcinosis.
  • MRI is of limited utility in evaluating calcified structures, but calcific deposits have characteristic patterns. The granulomatous foreign body reaction in tumoral calcinosis is evident.

Procedures

  • Findings on biopsy and histopathologic examination of a cutaneous lesion are diagnostic.
  • Results of fine-needle aspiration cytology of a skin nodule may also be diagnostic.

Histologic Findings

On biopsy, granules and deposits of calcium are seen in the dermis, with or without a surrounding foreign-body giant cell reaction. Alternatively, massive calcium deposits may be located in the subcutaneous tissue. In areas of necrosis, calcium deposition is frequently found within the walls of small and medium-sized blood vessels. Calcium deposition may be confirmed on Von Kossa and alizarin red stains.

More on Calcinosis Cutis

Overview: Calcinosis Cutis
Differential Diagnoses & Workup: Calcinosis Cutis
Treatment & Medication: Calcinosis Cutis
Follow-up: Calcinosis Cutis
Multimedia: Calcinosis Cutis
References
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References

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Further Reading

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Keywords

cutaneous calcinosis, cutaneous calculi

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Contributor Information and Disclosures

Author

Julia R Nunley, MD, Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center
Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, and Women's Dermatologic Society
Disclosure: Johnson and Johnson stock holder dividends; Amgen stock holder dividends; Forest Lab, Inc stock holder dividends; Galaxo Smith Klein stock holder dividends; Covidien stock holder dividends; Novartis Grant/research funds Consulting; Biolex  sub-investigator

Coauthor(s)

Lydia M E Jones, MD, Staff Physician, Department of Dermatology, Virginia Commonwealth University
Disclosure: Nothing to disclose.

Medical Editor

James W Patterson, MD, Director of Dermatopathology, Professor of Pathology and Dermatology, Departments of Pathology and Dermatology, University of Virginia Medical Center
James W Patterson, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Medical Association, American Society of Dermatopathology, Medical Society of Virginia, Royal Society of Medicine, Society for Investigative Dermatology, and United States and Canadian Academy of Pathology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Rosalie Elenitsas, MD, Herman Beerman Associate Professor of Dermatology, University of Pennsylvania School of Medicine; Director, Penn Cutaneous Pathology Services, Department of Dermatology, University of Pennsylvania Health System
Rosalie Elenitsas, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

 
 
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