Dysthrophic calcification in Systemic Sclerosis – Intralesional Injections of Sodium Thiosulfate may have significant Positive Effects on your patients

Abstract

To describe our three year experience with intralesional injection of sodium thiosulfate (STS) as treatment for dystrophic calcification (DC) in patients suffering from systemic sclerosis (SSc), overlap syndrome, or dermatomyositis. Methods: Between September 2016 and October 2019, selected SSc, overlap syndrome, and dermatomyositis patients with problematic DC were systematically and prospectively recruited to treatment once a week for four weeks and follow up after 12-16 weeks. During each visit, data concerning DC size, ulceration, inflammation, and both patient and physician global score (1-10) (PtGA and PhGA) were collected on customized data sheets. The DC lesions were injected with STS 150mg/ml on top or in the upper part of the lesion by the same clinician. After treatment, the lesion was covered up with a pressure distributing plaster for at least 24 hours. Results: Among 43 patients offered treatment, 38 patients, 33 women and 5 men, had one or more problematic DC treated with intralesional STS. The total number of treatments was 463. The patients had between 1 and >200 DC lesions and at each session between 1 and 22 lesions were treated. A total of 36 series consisting of 4 treatments were performed in 29 patients, 26 women and 3 men. Among these patients, 18 had systemic sclerosis of limited cutaneous type (lcSSc), 8, 2, and 1 patient had systemic sclerosis of diffuse cutaneous type (dcSSc), overlap syndrome, and dermatomyositis respectively. The average PtGA and PhGA before treatment was 6.4 and 6.1 respectively. A significantly decrease of the average PtGA and PhGA score was observed week by week and after the third treatment the average decrease in PtGA and PhGA was 2.7 and 2.5 respectively (p<<0.001). Almost all patients experienced intense pain during and after injection (up to several minutes), but otherwise side effects were few and not serious. Conclusions: We find that intralesional STS injections have positive effect with limited side effects on selected SSc patients with problematic DC. We recognize the limitations of the study design leaving plenty of questions to be addressed. It is our clinical impression that patient, lesion, and clinician related factors may influence the outcome of the treatment. We hope that our treatment regimen may inspire physicians to consider STS injections as a possible treatment for troublesome DC before referring to surgical interventions.

Local, non-systemic, and minimally invasive therapies for calcinosis cutis: a systematic review

“… Er:YAG erbium-doped yttrium aluminium garnet, ESWL extracorporeal shockwave lithotripsy, N/A not applicable, N/R not reported, STS sodium thiosulfate a Missing data were managed by available case analysis and mean imputation was used when a mean was known for a variable of interest but exact values were not reported for individual cases from a single study b Olesen et al [ 17 ] also reported injection pain, however, without an exact number of cases experiencing it c A group of patients was too small d Bottomley et al [ 13 ] reported outcomes as for particular lesions instead of describing overall response in each patient …”

“…A total of 410 articles were retrieved from the search. Additionally, ten more studies were added after the manual screening of the reference sections [10,[17][18][19][20][21][22][23][24][25]. Eight articles were excluded at the eligibility stage due to reporting patients described in other included studies [20,26,27] or insufficient data [24,25,[28][29][30].…”

“…Included articles consisted of one prospective double-blind placebo-controlled pilot study [22], 7 case series [4,5,10,13,17,18,21,[31][32][33][34][35], and 27 case reports [36][37][38][39][40][41][42][43][44]. Five conference abstracts were included [19,21,33,45,46].…”

“…Some patients were prescribed with nonsteroidal anti-inflammatory drugs or paracetamol after the procedure. Postoperative management included an ointment or cream of Table 2 Summary of local, non-systemic, and minimally invasive treatment options for calcinosis cutis Er:YAG erbium-doped yttrium aluminium garnet, ESWL extracorporeal shockwave lithotripsy, N/A not applicable, N/R not reported, STS sodium thiosulfate a Missing data were managed by available case analysis and mean imputation was used when a mean was known for a variable of interest but exact values were not reported for individual cases from a single study b Olesen et al [17] also reported injection pain, however, without an exact number of cases experiencing it c A group of patients was too small d Bottomley et al [13] healing and soothing properties [55], often combined with antimicrobials such as chlorhexidine [50], mupirocin [13,52], fusidic acid [35,44], and povidone-iodine [53].…”

“…Top-STS may be investigated as potential treatment for lesions disqualified from conventional surgery (i.e. disseminated and extensive lesions and these located in anatomically critical sites [5,17,62]). Some patients with a history of unsuccessful therapy with top-STS respond to IL-STS [10,30], laser [45], and ESWL [57].…”