A New Treatment Regimen for Rosacea: OnabotulinumtoxinA

December 2012 | Volume 11 | Issue 12 | Original Article | 76 | Copyright © December 2012

Steven H. Dayan MD,a Rachel N. Pritzker MD,b and John P. Arkins BSc

aClinical Assistant Professor, University of Illinios Department of Otolaryngology, Chicago, IL bDepartment of Medicine, Division of Dermatology, John H.Stroger Jr. Hospital of Cook Country, Chicago, IL cDeNova Research, Chicago, IL

Rosacea is a cutaneous condition with several clinical subtypes that are commonly seen in daily medical practice. There are many different treatment modalities for each of the physical findings associated with this disease, and all have varying results. As the use of onabotulinumtoxinA rises, its benefit in the treatment of a growing number of medical diseases increases. The authors report anecdotal evidence of patients with rosacea experiencing improved symptoms of erythema and flushing after treatment with intradermal, microdroplets of onabotulinumtoxinA. There were no adverse events reported for any of the treatments. The mechanism of action through a likely neurogenic component to vascular dysfunction, inflammation, and hypersebaceous activity is reviewed.

J Drugs Dermatol. 2012;11(12):e76-e79.


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