Subepidermal calcified nodule (SCN) of the ocular adnexa is a rare, benign subtype of calcinosis cutis. It typically arises as a painless lesion in young African American or Hispanic males. The nodules are classically described as yellow-white, mobile and firm. Complete surgical excision with histopathologic examination is diagnostic as well as curative.
Calcinosis cutis describes the abnormal deposition of calcium in the skin. It may divided into 5 subtypes: dystrophic, metastatic, iatrogenic, SCN and calciphylaxis.  SCN was first described by Winer in 1952, and several cases have since been reported on the ocular adnexa.
The pathogenesis of SCN remains unclear, as it typically arises in the setting of normal serum calcium levels and in the absence of systemic disease. The condition is notably distinct from CREST syndrome (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia).Proposed mechanisms include preexisting lesions, mast cell degranulation, calcification of sweat gland ducts and prior trauma or infection.Patient historical data are largely inconsistent with trauma, making dystrophic calcification unlikely. Similarly, correlation with milia and syringomas have been reported, but a causal link has not been proven. The theory of mast cell degranulation leading to secondary calcium deposition is supported by multiple histopathologic studies, however further research is necessary.
Reported cases of SCN demonstrate a 2:1 male predominance, with a racial predilection for African Americans and Hispanics.A review of 43 cases of SCN found that 63% occurred in “non-Caucasians”. Although SCN has been reported in every age group, the majority (>90%) of cases occur in patients younger than 21 years of age.
A thorough history should be performed to assess for underlying malignancy, rheumatological conditions, and disorders of calcium homeostasis. Clinicians should be aware that SCN is commonly overlooked or misdiagnosed.One review found that 76% of patients sought medical care >6 months after discovering the lesion. The high rate of clinical misdiagnosis makes histopathologic examination necessary.
SCN rarely involves the ocular adnexa. In a review of the 146 previously reported cases of SCN, only 53 (36%) were found to have eyelid involvement. Most nodules measured <5mm, with the majority arising on the upper eyelid or medial canthus. SCN typically presents as an asymptomatic, unilateral lesion, although cases of multiple and bilateral nodules have been described. The nodules appear yellow-white with raised, wart-like features. On manipulation, the nodules are firm and mobile.
Hematoxylin and eosin staining reveals an acanthotic or hyperkeratotic epidermis overlying basophilic calcium deposition in the upper dermis. "> Large amorphic deposits and small calcified globules have both been described. The Von Kossa staining protocol is commonly used to confirm the presence of calcium deposition (positive, black staining). Mast cells surrounding the calcification and chronic inflammatory giant cell reaction may also be identified, particularly in younger patients.
- Sebaceous cyst.
- Seborrheic keratosis.
- Cutaneous horn.
- Mulluscum contagiosum.
- Other subtypes of calcinosis cutis (metastatic, dystrophic).
Definitive treatment of SCN is by surgical excision. Intralesional corticosteroid injection, topical steroid use, and saucerization with electrodessication have all been proposed, but their use is limited and evidence is lacking. Incomplete excision has demonstrated recurrence, so long-term follow up is encouraged.
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