Calcinosis cutis is a condition of accumulation of calcium salts within the dermis leading to the formation of a calcified mass. This complication has been reported in acne vulgaris and other systemic metabolic disorders. This paper presents a rare case of calcinosis cutis in a 14-year-old male which was found at a routine orthodontic assessment.
Acne vulgaris (AV) is a benign dermatological condition resulting from overproduction of sebum by the skin’s sebaceous glands. The condition commonly occurs in adolescents and young adults. It primarily affects the face, upper back, and chest, producing two types of lesions, inflammatory lesions and comedones. Physical sequelae of the condition such as scar formation and hyperpigmentation are common, but rarer sequelae such as cutaneous calcifications are infrequently reported in the literature [
Calcinosis cutis occurs as a result of the deposition of calcium salts in the dermis and subcutaneous tissues. This complication has not only been reported in AV and systemic metabolic disorders such as hyperparathyroidism, infection, or connective tissue disorders but can also occur following trauma to an area of the skin. Calcinosis cutis can be subdivided into 4 groups based on aetiology: dystrophic, metastatic, iatrogenic, and idiopathic [
This paper presents a case report of dystrophic calcinosis cutis in a 14-year-old male, resulting from inflammatory facial acne.
A Caucasian male aged 14 years attending an orthodontic clinic for a routine assessment presented with an incidental radiographic finding. A well-defined calcified mass was visible at the apex of the maxillary right permanent canine on the orthopantomogram (OPG) radiograph (Figure
OPG radiograph taken prior to orthodontic treatment showing a calcified mass above the apex of the upper right canine.
A lateral cephalometric radiograph showed that this mass was significantly superior to the dentition in the antral inferior nasal region (Figure
Lateral cephalometric radiograph taken prior to orthodontic treatment showing a calcified mass above the apex of the upper right canine.
This calcified mass had not been present on the OPG radiograph taken previously, at age 10 years (Figure
OPG radiograph taken 4 years previously with no evidence of the calcified mass seen on the later radiographs.
From the age of 12, it was reported that the patient suffered with facial AV. He attended a consultant dermatologist who treated the condition successfully. The calcified mass was previously assessed at dermatological review. Despite the fact that it was a solitary lesion, it was diagnosed as dystrophic calcinosis cutis. The dermatologist advised no intervention as there was a significant risk of facial scarring if surgically removed. The mass was asymptomatic and presented little risk of infection. The patient was placed on annual review with his dermatologist.
Although the mass was palpable and mobile, the patient’s dermis was intact and acne-free. The mass was not visible clinically on extraoral examination. Facial profile and contour were normal. Orthodontically, he presented with a Class III incisor relationship on a Class III skeletal base with crowding in the maxillary arch. Both the patient and his parents were given the option of orthognathic surgery to treat his malocclusion and underlying significant skeletal relationship discrepancy. After extensive discussions and reviews with a maxillofacial surgeon, they opted for orthodontic treatment only, namely, alignment of the maxillary arch teeth on a non-extraction basis, followed by permanent retention. The orthodontic treatment was uneventful and successful.
Acne vulgaris is a dermatological disease caused by changes in the hair follicle and its associated sebaceous gland, jointly called the pilosebaceous unit. AV affects approximately 80% of the population between 12 and 25 years of age. It does not display race or gender prevalence differences [
Comedones are subdivided into blackheads and whiteheads. A blackhead is a comedone which is open to the skin surface allowing the contents to escape. The black colour is due to melanin pigmentation. The whitehead is a closed comedone, which does not allow its contents to escape.
Inflammatory lesions arise if the walls of a closed comedone rupture. Lipoid tissue is expressed into the surrounding dermis. This sets up a foreign body inflammatory reaction and coupled with
Healing of the AV inflammatory lesions can occur via two processes. Firstly, healing by fibrous tissue can lead to scar formation, while secondly, the epidermis portion of the remaining comedone walls sends out sheaths of epithelium to encapsulate any inflammatory material. The encapsulated mass can become thickened by the evaporation or absorption of fluid. This thickened mass, coupled with necrotic tissues, which are produced as part of healing, provides an ideal environment for the formation of calcifications known as calcinosis cutis [
Calcinosis cutis is characterized by abnormal deposits of calcium salts in the dermis and/or hypodermis. It often presents as multiple hard pale plaques, nodules, or papules; however, it can present as a singular lesion also [
Dystrophic calcinosis cutis occurs in areas of tissue damage secondary to infection, inflammatory processes, connective tissue diseases, or cutaneous neoplasms [
Dystrophic cutaneous calcification secondary to long-term acne was first reported in 1928 by Hopkins [
Diagnosis of dystrophic calcinosis cutis is based on serological investigations, suitable imaging, and biopsy if required [
Due to its radiopaque nature, dystrophic calcinosis cutis can be visualized on plain film radiographs; however, other useful modalities which could have been used include cone beam computed tomography (CBCT) and ultrasound [
In cases of diffuse calcinosis cutis, such as metastatic or iatrogenic, medical management is required to correct the systemic imbalance. This includes the use of warfarin, bisphosphonates, minocycline, ceftriaxone, diltiazem, aluminium hydroxide, probenecid, intralesional steroids, and intravenous immunoglobulin [
Dystrophic calcinosis cutis can occur as a sequela of long-term AV or alongside underlying metabolic disorders. Dentists should be aware of this phenomenon, as it can occur in the facial region and may present as an incidental finding on routine dental radiographs, both intra- and extraoral.
The authors declare no conflicts of interest.