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

and this may have an effect on the outcome. Sample sizes are small, and no large, placebo-controlled trials have been conducted to date.
In addition to flushing, hypersebaceous activity is characteristic in many patients with rosacea, especially those with a glandular type.3 Excess sebum production is also a frequently implicated component of acne vulgaris. In a large meta-analysis of patients treated with onabotulinumtoxinA for facial lines, acne was statistically significantly less common in the onabotulinumtoxinA- treated participants than in the placebo group,18 suggesting that onabotulinumtoxinA may have a therapeutic effect on acne reduction. Although a mechanism of action has not been clearly identified in explaining the botulinum toxin type A effects on reducing acne, there is speculation that the neuropeptides ACh and SP may be a neurogenic origin of both sebaceous activity and inflammation.19 Moreover, botulinum toxin type A at 2 U/0.1 cc dilution, a known inhibitor, has been reported to reduce oily skin and the appearance of pore size when injected intradermally into facial skin.20 Other studies have also indicated that intradermal injections on onabotulinumtoxinA and abobotulinumtoxinA improve the aesthetic appearance of the skin.21
Similar to the technique used for hyperhidrosis and oily skin, the effectiveness in reducing symptoms of rosacea along with preventing adverse muscular dysfunction seems dependent on injecting the toxin intradermally. We selected a higher dilution (100 U/7 cc), recognizing that it allows for more spread22 and, in theory, also reduces the potency of any product that penetrates past the dermal subcutis junction to reach a specific muscle group, thereby reducing the possibility of mimetic complication.


The ability to offer a treatment that takes just minutes and can be performed three to four times per year, obviating the need for multiple laser treatments, systemic medications, or daily topical treatments, would provide a desirable alternative for both the patient and the physician. Rosacea affecting the face can be a major disruption in one's professional, social, and family life. Surveys by the National Rosacea Society indicate that more than 76% of rosacea patients find that the condition lowers their self-confidence and self-esteem, with 41% reporting that it causes them to avoid public contact or cancel social engagements.3 The proposed mechanisms of action responsible for botulinum toxin efficacy in reducing the symptoms of rosacea are logical, but still not clearly delineated. Perhaps by inhibiting release of VIP and ACh, botulinum toxin is inhibiting the effects of two of the known neurogenic peptides linked to inflammation and vasodilation in rosacea, or perhaps, the exact mechanisms are yet to be identified by which botulinum toxin prevents the release of one of the numerous other neuropeptides involved in sebaceous activity, vascular homeostasis, and inflammation.
While our results are anecdotal, the curious nature of this product continues to expand serendipitously to new indications. A double-blind, randomized, placebo-controlled trial is in order and expected soon.


Dr. Dayan has been a consultant, investigator, and speaker for Merz, Medicis, and Allergan.


  1. Botox® [product insert]. Irvine, CA: Allergan Inc; 2011. http://www.allergan. com/assets/pdf/botox_pi.pdf. Accessed October 9, 2012.
  2. Botox® Cosmetic [product insert]. Irvine, CA: Allergan Inc; 2011. http://www. allergan.com/assets/pdf/botox_cosmetic_pi.pdf. Accessed October 9, 2012.
  3. Crawford GH, Pelle MT, James WD. Rosacea: I. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol. 2004;51(3):327-341.
  4. Wilkin J, Dahl M, Detmar M, et al. Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea. J Am Acad Dermatol. 2004;50(6):907-912.
  5. Olday J, Currie E, Drummond GB. The incidence of flushing on induction of anaesthesia in patients who blush easily. Anaesthesia. 2003;58(3):275-277.
  6. Drummond PD, Lance JW. Facial flushing and sweating mediated by the sympathetic nervous System. Brain. 1987;110(Pt 3):793-803.
  7. Schwab VD, Sulk M, Seeliger S, et al. Neurovascular and neuroimmune aspects in the pathophysiology of rosacea. J Investig Dermatol Symp Proc. 2011;15(1):53-62.
  8. Holowatz LA, Thompson CS, Minson CT, Kenney WL. Mechanisms of acetylcholine- mediated vasodilatation in young and aged human skin. J Physiol. 2005;563(Pt 3):965-973.
  9. Bennett LA, Johnson JM, Stephens DP, Saad AR, Kellogg DL Jr. Evidence for a role for vasoactive intestinal peptide in active vasodilatation in the cutaneous vasculature of humans. J Physiol. 2003;552(Pt 1):223-232.
  10. Yuraitis M, Jacob CI. Botulinum toxin for the treatment of facial flushing. Dermatol Surg. 2004;30(1):102-104.
  11. Tugnoli V, Marchese Ragona R, Eleopra R, et al. The role of gustatory flushing in Frey's syndrome and its treatment with botulinum toxin type A. Clin Auton Res. 2002;12(3):174-178.
  12. Uprus V, Gaylor JB, Carmichael EA. Localized anormal flushing and sweating on eating. J Nerv Ment Dis. 1937;85(6):724.
  13. Young AG. Unilateral sweating of the submental region after eating. Br Med J. 1956;2(4999):976-979.
  14. Drummond PD. Mechanism of gustatory flushing in Frey's syndrome. Clin Auton Res. 2002;12(3):144-146.
  15. Sterodimas A, Nicolaou M, Paes TR. Successful use of Botulinum toxin-A for the treatment of neck and anterior chest wall flushing. Clin Exp Dermatol. 2003;28(6):592-594.
  16. Kranendonk SK, Ferris LK, Obagi S. Re: Botulinum toxin for the treatment of facial flushing. Dermatol Surg. 2005;31(4):491; author reply 492.
  17. Alexandroff AB, Sinclair SA, Langtry JA. Successful use of botulinum toxin A for the treatment of neck and anterior chest wall flushing. Dermatol Surg. 2006;32(12):1536.
  18. Brin MF, Boodhoo TI, Pogoda JM, et al. Safety and tolerability of onabotulinumtoxinA in the treatment of facial lines: a meta-analysis of individual patient data from global clinical registration studies in 1678 participants. J Am Acad Dermatol. 2009;61(6):961-970. e1-11.
  19. Zouboulis CC. Acne and sebaceous gland function. Clin Dermatol. 2004;22(5):360-366.
  20. Shah AR. Use of intradermal botulinum toxin to reduce sebum production and facial pore size. J Drugs Dermatol. 2008;7(9):847-850.
  21. Petchngaovilai C. Midface lifting with botulinum toxin: intradermal technique. J Cosmet Dermatol. 2009;8(4):312-316.
  22. Hsu TS, Dover JS, Arndt KA. Effect of volume and concentration on the diffusion of botulinum exotoxin A. Arch Dermatol. 2004;140(11):1351-1354.


Steven Dayan MDsdayan@drdayan.com