Sodium thiosulfate dressings facilitate healing of refractory cutaneous ulcers of calcinosis cutis.

A 62-year-old man presented to our hospital in 2014 with non-healing ulcers in right 3rd and 4th toes. He was completely devoid of scalp and body hair (alopecia totalis); had salt and pepper like appearing skin over back and legs; pinched nose; thick and tight skin in hands and feet. The skin over his feet was remarkable for multiple callosities (some of which were causing recurrent non-healing ulcers). X-ray of foot revealed multiple soft tissue calcifications and biopsy showed hyperkeratosis, parakeratosis of epidermis with focal calcifications in dermis- being diagnostic of calcinosis cutis. He had undergone cataract surgery in both eyes at the age of 38 years and was detected to have diabetes at the age of 44 years. His serum calcium, serum phosphate, and urinary calcium levels were normal. He was worked up for the differentials of connective tissue disorders including scleroderma but was not manifesting Raynaud's phenomenon, telangiectasia, esophageal dysmotility or pulmonary dysfunction and his extractable nuclear antigen (ENA) panel was negative. Considering his appearance suggestive of premature ageing, cataract surgeries in both eyes at young age and calcinosis cutis (radiological and biopsy proven) over Achilles tendon—a diagnosis of Werner syndrome was made.[1] Subsequently he was lost to follow up.

In September 2017 he presented with a large oval shaped ulcer over right Achilles tendon measuring 13 × 6 cm, chalky, and greasy base with slough, perpendicular margins, and normal edge [Figure 1a]. Another oval ulcer over lateral malleolus of 5 cm diameter, exposing tissues with slough at base was present for 4 months [Figure 1b]. He had undergone debridement, unsuccessful grafting and was taking hyperbaric oxygen therapy elsewhere and since there was no improvement despite 10 sessions, he had reported to us. During re-evaluation in our hospital, arterial doppler in his right leg showed biphasic flow pattern in anterior tibial, popliteal, peroneal arteries with diffuse arterial wall calcification. He underwent slough excision with debridement and was started on regular 10% sodium thiosulfate (STS) topical dressings. His deep wound swab grew Pseudomonas spp and was started on piperacillin-tazobactum for 1 week. Subsequently on follow up he grew same organism and was on another 1-week course of antibiotic twice. After 5 months as he had adequate granulation, skin was grafted, and wound care continued with STS dressings. There was dramatic improvement and healing over next 4 months gradually in both Achilles [Figure 2a] and lateral malleolar ulcers [Figure 2b]. He is still under regular follow up and has not developed ulcers in same region over the subsequent 6 months.

Figure 1

(a) Achilles tendon ulcer and (b) Lateral malleolus ulcer at presentation after 1 year of recurrent debridement, skin grafting and hyperbaric oxygen therapy

Figure 2

(a) Achilles tendon ulcer and (b) Lateral malleolar ulcer after 9 months of regular 10% sodium thiosulfate dressings and skin grafting

Calcinosis cutis is a chronic condition wherein calcium salts deposit in dermal layers. There are numerous causes of calcinosis, one of the dystrophic cause being Werner syndrome.[2] Since there is no cure for the condition, management is very difficult especially when there is a break in epidermis. STS has been used in medicine for calcium chelation, to reduce cisplatin toxicity and previously for tinea versicolor.[3] Topical STS has been documented to help in cases of refractory, non-healing calcinosis wounds frequently found in connective tissue disorders (CTD), and tumoral calcinosis.[4] In our literature search, STS has not been used for any other cutaneous ulcers. Recent literature shows up to 70% of those with CTD and calcinosis ulcers responded to topical STS.[5] Topical STS, apart from chelation also has a role in nitric oxide synthase regeneration, endothelial protection, and blocking cell trans-differentiation.[4] This communication is intended to document that STS can be used effectively in treating refractory ulcers of calcinosis cutis.

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The authors certify that appropriate patient consent was obtained.

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Conflicts of interest

There are no conflicts of interest.