A New Treatment Regimen for Rosacea: OnabotulinumtoxinA

an adjunct to intense pulsed light (IPL) treatments, which had been our treatment of choice. However, we have subsequently abandoned the IPL treatment, recognizing it as no longer necessary because the efficacy of botulinum toxin appears to be singularly adequate for a three-month period.

A 59-year-old Caucasian female presented with focally increased telangiectasias, persistent erythema focused on the malar cheeks and nose, and facial flushing triggered by heat and/or stress. Her past medical history was noncontributory, her history of sun exposure was moderate, and she had not previously received any cosmetic treatments or prescription agents for these clinical concerns. Physical examination revealed prominent telangiectasias on the malar cheeks and nose overlying a background of illdefined erythema, and the patient reported a burning sensation during facial flushing episodes. Also noted were fine rhytides of the forehead, glabella, and periocular areas.

Because the patient was concerned with both of these physical findings, possible treatment options were reviewed, and it was decided to use one treatment modality for both concerns, the injection of a neuromodulator, onabotulinumtoxinA. After informed written consent was obtained, the botulinum toxin A was diluted with 7 cc of isotonic saline to create a final dilution of 1.4 units per 0.1 cc. Using a 30-gauge needle, six units were injected into the right cheek and four units were injected into the left cheek in a microdroplet intradermal technique at 0.5 cm intervals. At a two-week follow-up appointment, the patient noted a substantial decrease in erythema of the bilateral cheeks (Figure 1). There were no side effects reported, including paralysis or asymmetry. Pleased with clinical results that had lasted approximately three months, the patient requested another treatment. At this treatment, 11.2 units total were injected into each cheek and 5 units into the nasal affected skin. Again, the patient reported a decrease in the amount of erythema at the affected area.

A 50-year-old Caucasian female presented over many years with persistent erythema, intermittent flushing, and telangiectasias on her cheeks and glabella. She had previously been treated with microdermabrasion and over-the-counter topical treatments without success. Her medical history was noncontributory, and her history of sun exposure was moderate. Physical examination revealed generalized erythema of the bilateral cheeks and glabella areas, with increased telangiectasias on the malar cheeks. After discussing available treatment options, a series of IPL treatments (Harmony System; Alma Lasers Ltd, Caesarea, Israel) was initiated on the full face. The initial treatment parameters included a wavelength 530 nm to 950 nm, energy of 16 J/cm², 15 ms pulse duration, and one pass over the full face. A total of eight treatments was completed over a year and half, resulting in only mild improvement in the background erythema. Subsequently, an additional two IPL treatments were performed with the Lumenis M22 platform (Lumenis Ltd, Yokneam, Israel), using settings of a wavelength 590 nm to 1,200 nm, energy of 13 J/cm² to 18 J/cm², 4 ms triple pulse duration, with one pass over the cheeks, resulting in only mild improvement in the erythema.

Using the same microdroplet intradermal technique outlined in case 1, 11.2 units of onabotulinumtoxinA were injected evenly throughout the clinically affected area of the cheek and glabella at 0.5 cm intervals. The patient tolerated the procedure well. There were no side effects, and a marked improvement in the evident erythema was noted at her 10-day follow-up appointment. At this visit, the procedure was repeated again with the same treatment parameters. The patient reported a considerable reduction in the pore size, erythema, and flushing of the affected areas one month after treatment (Figure 2). No side effects were noted. As the patient was satisfied with the results, she returned for another treatment four months after the initial treatment with onabotulinumtoxinA.

It is important to recognize the subtype of rosacea, because the pathophysiology, clinical course, and outcomes can vary among them. However, vascular abnormality is perhaps the