Worldwide, botulinum neuromodulators are now
the most popular medical treatment for wrinkle
reduction, but its storied history and broad-based
applications for treating many noncosmetic medical conditions
go back further. The Food and Drug Administration (FDA) initially
approved it in 1989 for strabismus and soon after for cervical
dystonia, and there have been six additional indications
since then.1,2 The advancement and evolution of additional indications
seem consistently to outpace many other pharmaceuticals.
It seems the quest for new uses for botulinum toxin is
uncontained, and limited only by the imagination.
Interestingly, many of the newer indications, from migraines to
hyperhidrosis, have been stumbled upon serendipitously while
treating a recognized indication. In our own experience, we anecdotally
noticed that, following a cosmetic treatment to the
glabella and the forehead area with onabotulinumtoxinA, there
was not only a reduction in wrinkle formation, but also a curious
skin-quality change that appeared to be the result of light reflecting
robustly off a smooth, homogenous skin surface. There also
appeared to be a reduction in acneic lesions and peripustule erythema
in treated areas. Recognizing that erythema, flushing, and
inflammation had been reduced in our patients with acne vulgaris
prompted us to use botulinum toxin empirically as a treatment
for relieving symptoms associated with rosacea.
Rosacea, a common condition affecting 16 million Americans, has
a variable presentation. The clinical diagnosis for rosacea can be
difficult to identify at times, but its most important sign is erythema
over the central face persisting for longer than three months.
Flushing, papules, pustules, and telangiectasias are other common
characteristic signs.3 A 2004 article published by leading experts
classified rosacea into four subtypes: erythematotelangiectactic, papulopustular, phymatous, and ocular.4 Erythematotelangiectactic
rosacea (ETR), characterized by flushing that persists for
longer than 10 minutes, can be brought on by different triggers
from emotional stress to foods to topical products. It is often
associated with burning and stinging, but not with palpitation,
light-headedness, or sweating. Papulopustular rosacea (PPR) is
the classical rosacea characterized by a red central portion of the
face with small papules that may be surmounted by pinpoint pustules.
Flushing occurs but is not as marked as in ETR. Persistent
or episodic inflammation is commonly seen, and the inflammation
may lead to chronic edema and fibrous changes to the skin.
Phymatous rosacea is characterized by marked skin thickening
and irregular surface nodularities leading to rhinophyma (nose),
gnathophyma (chin), and metophyma (forehead). The fourth type,
ocular rosacea, centers around the eyes. Other clinical considerations
for rosacea include glandular and granulomatous rosacea
represented by nodularities that can lead to scarring but are not
necessarily associated with flushing. Nonrosacea conditions such
as chronic sun damage, topical steroid abuse, and adverse drug
reactions may have similar symptoms to rosacea and should be
ruled out prior to diagnosing rosacea.
Over the past two years, we have treated 13 patients presenting
with rosacea with intralesional microdroplet injections (0.05 cc)
of onabotulinumtoxinA (Botox® Cosmetic; Allergan, Irvine, CA)
in a dilution of 7 cc of saline solution per 100 units.
Multiple injections were performed intradermally and ranged
on average from 8 to 12 units per affected cheek area. Decreased
flushing, erythema, and inflammation were noted
within one week and persisted for up to three months. When
we first started using botulinum toxin for rosacea, we used it as
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