Jordi | Journal of Oral Diagnosis Online Submission Review an Article SOBEP - Sociedade Brasileira de Estomatologia e Patologia Oral
Volume 3 - 2018

Original Article

DOI: 10.5935/2525-5711.20180021

Acne calcified scars: Case report

Mara Aparecida Barbosa de Sá; Natália Myrra Simões; Eduardo Silveira Rodrigues; Claudia Assunção e Alves Cardoso; Amaro Ilidio Vespasiano Silva; Flávio Ricardo Manzi

Ontifical Catholic University of Minas Gerais, Department of Dentistry - Belo Horizonte - Minas Gerais - Brasil

Corresponding authors: Flávio Ricardo Manzi

Article received on April 16, 2018
Article accepted on July 10, 2018



INTRODUCTION: The involvement of calcium regulatory factors in the epithelial tissue can result in calcification or cutaneous ossification. The secondary osteomas, wherein the calcification develops in a preexisting skin lesions such as acne, for example, are the most common.
OBJECTIVE: To report a case of calcification/ossification of soft tissues compatible with acne scarring.
CASE REPORT: Panoramic panoramic radiographic examination revealed radiopaque, circular image in the alveolar ridge region in the air corresponding to tooth 36, with residual root characteristics . The alteration in the diagnostic hypothesis occurred after periapical radiography, which revealed a displacement of the radiopaque image to the upper region of the border, confirmed by another radiograph with a film placed in the position between the vestibular face of the alveolar border and the mucosa of the cheek.
CONCLUSION: The radiographic findings associated with anamnesis and clinical examination suggested a diagnosis ofcalcification/ossification in soft tissue compatible with the healing of acne.

Keywords: Calcinosis; Ossification, Heterotopic; Acne Vulgaris



Calcium plays a vital role in the fundamental physiological regulatory events of many tissues, including the skin, and when the factors regulating this tissue are compromised, whether by local or systemic events, the result may be calcification (calcinosis) or ossification (osteoma)1.

Pathologically and radiographically the two conditions differ by the type of substance deposited in the skin, while ossification is characterized by deposition of organized bone matrix, calcification is defined by the accumulation of calcium salts2,3. For some authors, calcinose is considered a precursor or early manifestation of osteoma1.

Similar to calcification, the osteoma has a classification attributed to its etiology. calcification is divided into the metastatic, idiopathic, iatrogenic and dystrophic subtypes4. The metastatic type refers to the deposition of calcium salts as a result of increased serum calcium and/or phosphate levels4,5. In idiopathic calcification occurs in the presence of tissue and metabolic alterations1,5. The iatrogenic type is related to therapy or medical examinations6, while the dystrophic is characterized by an abnormal deposition of calcium salts in affected tissue1,7.

Cutaneous ossification can be classified as primary or secondary. The first occurs when there is no previous skin injury, as in diseases like Albright's hereditary osteodystrophy8. The secondary type in turn refers to the ossification process as a result of prior injury, trauma, inflammatory processes, scars, acne and others9-13.

Sites of calcification or heterotopic ossification may not generate any significant signs or symptoms and are usually only detected incidentally on routine radiographic examinations and by their benign and asymptomatic these conditions are often ignored feature coffee walk rare descriptions in literature image of Jácome & Abdo4, and White & Pharoah14.

Based on these assumptions, the objective of the present study was to report a clinical case calcification /ossification of soft tissues compatible with the healing of acne.


A 57-year-old man was referred to a Radiology Clinic for a routine panoramic radiograph. Radiographic examination revealed a radiopaque, circular image in the alveolar ridge region in the air corresponding to tooth 36, presenting characteristics similar to a residual root (Fig. 1).

Figure 1. Panoramic radiograph showing radiopaque, circular image in the alveolar ridge region in the air corresponding to tooth 36 (arrow).

For diagnostic confirmation a periapical radiography was performed using 70 kVp, 7 mA at a time of exposure of 0.41 seconds in the Gendex GX-770 device, which revealed a displacement of the radiopaque image to the upper region of the border, altering thus the residual root diagnosis hypothesis for soft tissue calcification/ossification (Fig. 2).

Figure 2. Periapical radiography , showing displacement of the radiopaque image to the upper region of the alveolar region of the tooth 36. Exposure time of 0.41 seconds (arrow).

The extra-oral physical examination was possible to observe small marks suggestive of acne scarring on the face of the patient, confirmed in history by reporting acneic skin history during adolescence. Intraorally, a nodule approximately 0.5 cm in diameter was observed in the cheek region near the labial commissure.The jugal mucosa was intact, asymptomatic and similar in color to the normal mucosa.

A new radiograph was taken by placing the periapical film in the position between the vestibular face of the alveolar border and the mucosa of the cheek and altering the exposure time to 0.10 seconds, which revealed a radiopaque, circumscribed and well defined (Fig. 3).

Figure 3. Periapical radiography performed with film positioned between the vestibular face of the alveolar border and the mucosa of the cheek. Exposure time: 0.10 seconds revealing radiopaque, circumscribed and well defined image (arrow).

The association of the findings obtained in the clinical and radiographic examination led to the conclusion of diagnosis as calcification/ossification of soft tissues compatible with the healing of acne.


Disorders of calcification or ossification of the skin are rare; however, when analyzed together, the findings of calcium deposits are common15. The pathogenesis of this process is still inconclusive. One of the most accepted theories is that chronic inflammation lead to the development of small calcifications and metaplastic ossification16,17.

Among the osteomas, the secondary ones are the most frequent18-21 representing about 70 to 85% of cases, and occurs when calcification develops in preexisting skin damage such as when there are secondary to the presence of a long term acne scar developed a chronic inflammatory dermatosis or9,22,23. Such findings corroborate with those of the case reported here, but the exact relationship between cutaneous osteoma and acne has not yet been clarified3.

Calcifications tend to occur generally at the same sites where acne lesions appear, and the face is the most common site of involvement20. Oral manifestations of the osteoma, with subcutaneous and mucosal calcifications, as in this report, are rare, and there is often confusion in the diagnosis of the lesions24.

There is a predominance of lesions in women, as evidenced in a previous study in which the files of a reference dermatopathology laboratory were investigated to identify cases of primary or secondary cutaneous ossification, and from the series of 74 cases analyzed the lesions were more commonly identified in female patients25. Fact that generates discussion on the role of estrogen in this process, however, this does not seem to be a crucial factor in the formation of osteoma, as women after menopause and men, as in the case presented in this study also develop lesions21.

The diagnosis of calcifications is usually performed by means of imaging tests, more commonly conventional and/or panoramic radiographs, often requested for other purposes25.

Soft tissue deposits usually present as radiopaque images of uniform contour and disc shape that can vary from 1 mm to a few centimeters in diameter, being single or multiple26.

When this calcification occurs in areas adjacent to the bone, usually the cheek and lips, it can be difficult to determine whether it is occurring within the bone or soft tissue itself, since in these locations the lesion image may overlap a dental root or alveolar process, giving an appearance of dense bone tissue area or a residual root14,23. And as reported here, a precise lesion location can be made by placing anintraoral film between the cheek and the alveolar process so that only the soft tissue is recorded. Another perpendicular radiographic incidence is also very useful in these cases.

To obtain a correct interpretation, it is important that points such as the anatomical location, number, distribution and shape of the calcifications are considered14. The importance of the differential diagnosis between calcifications is based on the different prognoses and treatments of each condition26.

For the secondary calcifications the acne scar, as in the case presented, no type of treatment is necessary, however there are cases and m depending on the location the excision of the lesions can be performed for aesthetic reasons14,22.


Conducting a detailed anamese combined with a comprehensive physical examination and the help of laboratory tests, were conducted as in this case, they are essential for making the diagnosis and definition of precise prognosis for each condition.


1. Walsh JS, Farley JA. Calcifying disorders of the skin. J Am Acad Dermatol. 1995;33(5 Pt 1):693-706.

2. Fazeli P, Harvell J, Jacobs MB. Osteoma cutis (cutaneous ossification). West J Med. 1999;171:243-5.

3. Gfesser M, Worret WI, Hein R, Ring J. Multiple primary osteoma cutis. Arch Dermatol. 1998;134:641-3.

4. Jácome AMSC, Abdo EN. Aspectos Radiográficos das Calcificações em Tecidos Moles da Região Bucomaxilofacial. Odontol Clín Cient. 2010;9:25-32.

5. Touart DM, Sau P. Cutaneous deposition diseases. Part II. J Am Acad Dermatol. 1998;39(4 Pt 1):527-44.

6. Sawke GK , Rai T, Sawke N. Iatrogenic calcinosis cutis: A rare cytological diagnosis. J Cytol. 2016;33:166-8.

7. Sardesai VR, Gharpuray MB. Calcinosis cutis. Indian J Dermatol Venereol Leprol. 2003;69:45-6.

8. Roth SI, Stowell RE, Helwig EB. Cutaneous ossification. Report of 120 cases and review of the literature. Arch Pathol. 1963;76:44-54.

9. Alhazmi D, Badr F, Jadu F, Jan AM, Abdulsalam Z. Osteoma Cutis of the Face in CBCT Images. Case Rep Dent. 2017;2017:8468965.

10. Altman JF, Nehal KS, Busam KJ, Halpern AC. Treatment of primary miliary osteoma cutis with incision, curettage, and primary closure. J Am Acad Dermatol. 2001;44:96-9.

11. Cottoni F, Dell Orbo C, Quacci D, Tedde G. Primary osteoma cutis. Clinical, morphological, and ultrastructural study. Am J Dermatopathol. 1993;15:77-81.

12. Davis MD, Pittelkow MR, Lindor NM, Lundstrom CE, Fitzpatrick LA. Progressive extensive osteoma cutis associated with dysmorphic features: a new syndrome? Case report and review of the literature. Br J Dermatol. 2002;146:1075-80.

13. Mast AM, Hansen R. Multiple papules on the elbows. Congenital osteoma cutis. Arch Dermatol. 1997;133:777, 780.

14. White SC, Pharoah MJ. Radiologia Oral - Princípios e Interpretação. 5ª ed. Rio de Janeiro: Elsevier; 2007.

15. Bolognia JL, Jorizzo JL, Schaffer JV. Dermatologia. 3ª ed. Rio de Janeiro: Elsevier; 2015.

16. Ahn SK, Won JH, Choi EH, Kim SC, Lee SH. Perforating plate-like osteoma cutis in a man with solitary morphea profunda. Br J Dermatol. 1996;134:949-52.

17. Bergonse FN, Nico MM, Kavamura MI, Sotto MN. Miliary osteoma of the face: a report of 4 cases and review of the literature. Cutis. 2002;69:383-6.

18. Am Conlin PA, Jimenez-Quintero LP, Rapini RP. Osteomas of the skin revisited: a clinicopathologic review of 74 cases. J Dermatopathol. 2002;24:479-83.

19. Haro R, Revelles JM, Angulo J, Fariña MC, Martín L, Requena L. Plaquelike osteoma cutis with transepidermal elimination. J Cutan Pathol. 2009;36:591-3.

20. Myllylä RM, Haapasaari KM, Palatsi R, Germain-Lee EL, Hägg PM, Ignatius J, et al. Multiple miliary osteoma cutis is a distinct disease entity: four case reports and review of the literature. Br J Dermatol. 2011;164:544-52.

21. Samaniego-González E, Crespo-Erchiga A, Gómez-Moyano E, Boz- González JD, Sanz-Trelles A. Perforans multiple osteoma cutis on the leg in a young woman. J Cutan Pathol. 2009;36:497-8.

22. Bouraoui S, Mlika M, Kort R, Cherif F, Lahmar A, Sabeh M. Miliary osteoma cutis of the face. J Dermatol Case Rep. 2011;5:77-81.

23. Levell NJ, Lawrence CM. Multiple papules on the face. Multiple miliary osteoma cutis. Arch Dermatol. 1994;130:370, 373-4.

24. Farhood VW, Steed DL, Krolls SO. Osteoma cutis: cutaneous ossification with oral manifestations. Oral Surg Oral Med Oral Pathol. 1978;45:98-103.

25. Vergamini GC, Parada MB, Hassun KM, Michalany N, Talarico S. Tratamento para os osteomas cutâneos múltiplos da FACE por excisão com agulha. Apresentação de três casos clínicos. Med Cutan Iber Lat Am. 2007;35:229-32.

26. Tamura T, Inui M, Nakasake M, Nakamura S, Okumura K, Tagawa T. Clinicostatical study of carotid calcification on panoramic radiographs. Oral Dis. 2005;11:314-7.


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