The Effectiveness of Topical Cerium Nitrate-Silver Sulfadiazine Application on Overall Outcome in Patients with Calciphylaxis

Dermatology. 2019;235(2):120-129. doi: 10.1159/000493975. Epub 2019 Jan 3.


Background: Calciphylaxis (CPX) is a rare and life-threatening disease characterized by vascular calcification and development of painful and necrotizing skin lesions with a challenging management. Mechanisms of CPX are complex and include an imbalance between vascular calcification promoters and inhibitors, and frequently vitamin K deficiency.

Objectives: To describe the various presentations and identify predictive factors of death in patients with CPX.

Methods: In this multicenter retrospective study, we included 71 CPX patients followed in South-West France (n = 26) and in French Polynesia (n = 45), and who all received sodium thiosulfate (25 g thrice weekly for a median of 61 days).

Results: Characteristics at presentation significantly differed between metropolitan and Polynesian French patients. Polynesians were less frequently on regular dialysis at the onset of CPX, had a higher incidence of diabetes mellitus and obesity, more disturbances of calcium-phosphorus metabolism, and received vitamin K antagonists less frequently than patients from South-West France. Despite intensive management, the 1-year mortality rate was 66% and median time to death was 200 days (IQR, 40; 514). The number of body areas involved (i.e., three: OR 2.70 [1.09; 6.65], p = 0.031; four: OR 8.79 [1.54; 50.29], p = 0.015) was the only predictive factor for death, whereas application of topical cerium nitrate-silver sulfadiazine was protective (OR 0.44 [0.20; 0.99], p = 0.046). Surgical debridement, hyperbaric oxygenation therapy, and geographical origin were not associated with overall outcomes.

Conclusions: Cerium nitrate may lead to vascular decalcification and chelation of reactive oxygen species, and prevent infection. Cerium nitrate-silver sulfadiazine was associated with better outcomes and should be tested in a prospective comparative trial in CPX patients.

Keywords: Calciphylaxis; Cerium nitrate-silver sulfadiazine; Outcome; Sodium thiosulfate.

Publication types

  • Multicenter Study

MeSH terms

  • Administration, Cutaneous
  • Aged
  • Anti-Infective Agents, Local / administration & dosage
  • Anti-Infective Agents, Local / therapeutic use*
  • Calciphylaxis / etiology
  • Calciphylaxis / therapy*
  • Cerium / administration & dosage
  • Cerium / therapeutic use*
  • Chelating Agents
  • Drug Combinations
  • Female
  • France
  • Humans
  • Kidney Failure, Chronic / complications
  • Kidney Failure, Chronic / therapy
  • Male
  • Middle Aged
  • Polynesia
  • Renal Dialysis
  • Retrospective Studies
  • Risk Factors
  • Silver Sulfadiazine / administration & dosage
  • Silver Sulfadiazine / therapeutic use*
  • Skin Diseases, Vascular / drug therapy*
  • Skin Diseases, Vascular / etiology
  • Survival Rate
  • Thiosulfates / therapeutic use
  • Treatment Outcome


  • Anti-Infective Agents, Local
  • Chelating Agents
  • Drug Combinations
  • Thiosulfates
  • cerium nitrate
  • Cerium
  • sodium thiosulfate
  • Silver Sulfadiazine