Introduction
Treating cutaneous calcifications poses a clinical challenge with limited satisfactory
treatment options. Dystrophic soft tissue calcifications are a potential long-term
cutaneous consequence of dermatomyositis.
1
Calcinosis deposits may be located in the skin, deep fascia, or intramuscular connective
tissue. These hard nodules are painful and may form a fistula and ulcerate, draining
chalky calcium through the skin. Treatment modalities with surgical excision and medications
such as diltiazem, bisphosphonates, and sodium thiosulfate have been used to control
calcinosis progression in dermatomyositis with limited success.
2
Carbon dioxide (CO2) lasers and shock wave lithotripsy have shown some efficacy, but
neither has yielded consistent clearance of cutaneous calcifications.
3
,
4
Acoustic shockwaves generated during picosecond lasers induce optical breakdown (LIOB)
creating cavitation bubbles in the skin.
5
The explosive vaporization and mechanical expansion caused by picosecond lasers within
the skin without harming the epidermis was theorized to be a good nonablative approach
to shatter calcification clusters before their extrusion. Using a large beam size
with the wavelength of 1064 nm was essential to contribute to skin penetration to
reach the overall cluster thickness. After this deep inner fragmentation for an enhanced
liquefaction, we used a fractionated ultrapulsed ablative CO2 laser to open deep 120-μm-wide
release channels. The fractional ablative CO2 lasers (Lumenis UltraPulse SCAAR FX;
Yokneam, Israel) allows a depth of 3.5 mm in a single, controlled pulse with minimal
collateral heating.
Case report
Here we present a case of ulcerated calcifications in the setting of dermatomyositis
in a 62-year-old female patient successfully treated with same-session picosecond
and ablative fractional CO2 laser. The patient had the calcifications for more than
10 years with significant pain. The patient had calcifications throughout her body;
however, the calcifications in the hip areas were ulcerating with increasing discomfort.
She did not respond to any prior pharmaceutical therapies. The right hip was treated
with 3 laser treatment sessions. The initial treatment was with the Picosecond Laser
(PiQo,
4
Lumenis) (1064 nm; fluence, 0.76 J/cm2; 800 ps pulse duration; 10 mm spot) immediately
followed by fractional ablative CO2 laser (Lumenis UltraPulse Encore) (energy, 90 mJ;
density, 3% 200 Hz), which resulted in a melting of the calcium into a liquid, which
easily extruded from the skin (Fig 1).
Fig 1
Before and during treatment. Before (Left) and during (Right) treatment with Picosecond
Laser (1064 nm; fluence, 0.76 J/cm2; 800 ps pulse duration 10 mm spot), immediately
followed by fractional ablative CO2 laser (energy, 90 mJ; scan size, 2 mm of fractionated
120-μm spots; pulse count, 1; density, 3% 200 Hz; topical Aquaphor). One month later,
the right hip was treated again with another round of fractional ablative laser (energy,
130 mJ; scan size, 2 mm of fractionated 120-μm spots; pulse count, 1; density, 3%
200 Hz; topical Aquaphor). During treatment, liquefied calcinosis cutis is extruded
from skin immediately after CO2 laser treatment.
One month later, the right hip was treated again with another round of fractional
ablative CO2 (energy, 130 mJ; scan size, 2 mm; pulse count, 1; density, 3% 200 Hz,
topical Aquaphor). This treatment resulted in significant clinical improvement with
presumed photoacoustic disruption of the calcinosis cutis subcutaneous nodules with
the picosecond laser followed by CO2 laser treatment to express the subcutaneous contents
after only 3 total laser treatment sessions (Figs 1 and 2).
5
Fig 2
Video of liquefied calcium extruding from skin after Ultrapulse – SCAAR Fx fractional
ablative CO2 laser treatment (submit for JAAD Instagram additionally).
Discussion
Calcinosis cutis can present a clinical challenge with a paucity of efficacious or
satisfactory treatment options with the use of picosecond lasers to disrupt the subcutaneous
calcium nodules sequentially followed by fractional ablative CO2 laser treatment.
Although this treatment regimen needs additional evaluation, it could be a minimally
invasive treatment option for patients with calcinosis cutis.