Low dose warfarin treatment for calcinosis in patients with systemic sclerosis

Abstract

Objective: To evaluate the effect of low doses of warfarin in patients with systemic sclerosis with disseminated subcutaneous calcinosis. Methods: Three patients with disseminated subcutaneous calcinosis were treated with low doses of warfarin for 1 year. Subcutaneous calcinotic lesions, coagulation blood parameters, and the tendency for bleeding were followed up during the year. Results: Two of the patients, who had newly diagnosed, diffuse, and relatively small calcinotic lesions, responded to warfarin treatment, with complete resolution of the calcinosis. The other patient, with larger and longer standing calcinotic lesions, did not respond to warfarin treatment. None of the three patients showed a prolongation of prothrombin time or partial thromboplastin time, nor did any have an increased tendency for bleeding. Conclusions: Low dose warfarin may serve as an effective treatment for calcinosis in a selected group of patients who have small and relatively new onset calcinosis. This treatment does not prolong the coagulation of blood and there is no increased tendency for bleeding. D iffuse calcinosis is a common manifestation of systemic sclerosis, mainly affecting the extremities.1 The subcutaneous calcium deposits may erode the skin and predispose these areas to secondary infection, yet no currently approved medical treatment exists. Rare anecdotal reports suggest that low dose warfarin may have a role in reducing the size of calcinotic plaques.2-4 We describe three patients who had multiple calcinotic lesions secondary to systemic sclerosis and who were treated with warfarin for 1 year, with results varying in accordance with the age and size of the calcinotic lesions. CASE REPORTSCase 1 A 35 year old female patient of Arab origin had limited cutaneous systemic sclerosis, manifested as severe Raynaud's phenomenon, oesophageal dysmotility, hidebound skin overlying both hands and face resulting in microstomia and puffy hands and pulmonary hypertension, positive antinuclear antibodies (three out of four), and negative anticentromere antibodies. Penicillamine treatment was ineffective, and the patient was treated with oral calcium channel blockers and with infusions of prostacyclin analogue.During follow up the patient was found to develop multiple painless subcutaneous calcium deposits on her knuckles and elbows, up to 2 cm in diameter. She consented to treatment with warfarin, which was started at a low dose of 1 mg/day. Within 2 months all the calcinotic lesions had completely disappeared, leaving only small areas of skin discolouration.Treatment was continued with warfarin for a year without recurrence of the calcinotic lesions. On follow up (at 2 years), no recurrence of the calcinotic lesions was seen. During treatment the prothrombin time (PT) and partial thromboplastin time (PTT) were repeatedly measured and were found to remain within normal values, with no clinically increased tendency for bleeding noted.Case 2 A 30 year old female patient of Arab origin was known to have had diffuse cutaneous system...

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