Various therapies have been studied for the prevention and treatment of scars. Many trials have focused on improving cosmetic appearance and reducing symptoms in hypertrophic and keloid scars, but less emphasis has been placed on therapies for normotrophic scars. Current guidelines cite compression and occlusive therapy, intralesional steroids, cryotherapy, laser therapy and surgical excision as first-line therapies for treating keloid and hypertrophic scars.12,13 Emerging therapies continue to be studied, including 5-fluorouracil, imiquimod, tacrolimus, retinoic acid, and verapamil.13 BTA has been studied as a monotherapy for treatment of scars with promising results. Multiple, small randomized controlled trials have shown BTA to be as effective as intralesional steroid injections at reducing volume of hypertrophic scars, improving pliability, erythema and itching.14 Studies of postoperative scar prevention with BTA have also shown promise.15 Regarding neuropathic pain, only one study and several case reports have demonstrated pain reduction in scars after injection with BTA.4,6,7 A single case report also described a durable reduction in neuropathic scar pain after 1 treatment of BTA for a 6-month-old Mohs surgery scar.8 Our patient described a pins and needles sensation at her melanoma excision scar consistent with neuropathic pain, which was refractory to multiple other treatments. Given the successful use of BTA in conditions with neuropathic pain and the few reports of pain reduction in keloid and Mohs scars, we hypothesized that BTA injection may yield therapeutic benefit in our patient as well. Our patient had marked, durable reduction in scar pain symptoms after treatment, indicating that BTA may be a viable treatment for painful normotrophic scars. However, further studies are needed to help determine the efficacy of BTA in treating painful hypertrophic, keloid, and normotrophic scars.
- Francisco GE, Tan H, Green M. Do botulinum toxins have a role in the management of neuropathic pain?: a focused review. Am J Phys Med Rehabil. 2012;91:899-909.
- Luvisetto S, Marinelli S, Cobianchi S, Pavone F. Anti-allodynic efficacy of botulinum neurotoxin A in a model of neuropathic pain. Neuroscience. 2007;145:1-4.
- Yuan RY, Sheu JJ, Yu JM, et al. Botulinum toxin for diabetic neuropathic pain: a randomized double-blind crossover trial. Neurology. 2009;72:1473-1478.
- Fabregat G, Asensio-Samper J, Palmisani S, et al. Subcutaneous botulinum toxin for chronic post-thoracotomy pain. Pain Pract. 2013;13:231-234.
- Ranoux D, Attal N, Morain F, Bouhassira D. Botulinum toxin type A induces direct analgesic effects in chronic neuropathic pain. Ann Neurol. 2008;64:274- 283.
- Uyesugi B, Lippincott B, Dave S. Treatment of a painful keloid with botulinum toxin type A. Am J Phys Med Rehabil. 2010;89:153-155.
- Shaarawy E, Hegazy RA, Abdel Hay RM. Intralesional botulinum toxin type A equally effective and better tolerated than intralesional steroid in the treatment of keloids: a randomized controlled trial. J Cosmet Dermatol. 2015;14:161-166.
- DePry JL, Mann M. Successful treatment of postoperative pain after Mohs micrographic surgery with onabotulinum toxin A. Dermatol Surg. 2017;43:1491-1494.
- Bock O, Schmid-Ott G, Malewski P, Mrowietz U. Quality of life of patients with keloid and hypertrophic scarring. Arch Dermatol Res. 2006;297:433- 438.
- Gurtner GC, Neligan PC. Vol 1: Principles. Plastic Surgery. 4th ed. London: Elsevier. 2017.
- Powers M, Ozog D, Chaffins M. Scar histopathology and morphologic classification. In: Krakowski AC, Shumaker PR, eds. The Scar Book: Formation, Mitigation, Rehabilitation, and Prevention. Philadelphia: Wolters Kluwer. 2017:59-71.
- Gold MH, McGuire M, Mustoe TA, et al. Updated international clinical recommendations on scar management: part 2 - algorithms for scar prevention and treatment. Dermatol Surg. 2014;40:825-831.
- Berman B, Maderal A, Raphael B. Keloids and hypertrophic scars: pathophysiology, classification, and treatment. Dermatol Surg. 2017;43:S3-S18.
- Kim YS, Hong ES, Kim HS. Botulinum toxin in the field of dermatology: novel indications. Toxins (Basel). 2017;9:E403.
- Giordano CN, Matarasso SL, Ozog DM. Injectable and topical neurotoxins in dermatology: indications, adverse events, and controversies. J Am Acad Dermatol. 2017;76:1027-1042.