Placement of High Dose Neurotoxins for Treatment-Resistant Rosacea

June 2023 | Volume 22 | Issue 6 | 605 | Copyright © June 2023


Published online May 10, 2023

doi:10.36849/JDD.7237

Channi Silence MSa, Arianne Kourosh MD MPHa,b, Erin Gilbert MD PhDd

aMassachusetts General Hospital, Boston, MA
bHarvard Medical School, Boston, MA
cGilbert Dermatology, New York, NY

Abstract
Rosacea is a chronic inflammatory skin condition characterized by facial flushing, erythema, telangiectasias, and papulopustular lesions. Treatment for rosacea includes limiting inciting factors and reducing inflammation with topical and oral therapies. Traditional therapies primarily focus on the papulopustular or background erythematotelangiectatic component of rosacea, leaving symptoms of flushing poorly controlled and profoundly impacting the quality of life of patients. Neuromodulators have been speculated to improve the flushing component of rosacea by reducing mast cell degranulation and the release of neuropeptides. However, its use for symptomatic relief in refractory flushing rosacea has been limited by side effects such as facial muscle weakness or paralysis. We present the use of strategic placement of high-dose neuromodulators for treatment-resistant rosacea. This approach has resulted in the gradual stabilization of symptoms, improved quality of life, and superior side effect profile.


Silence C, Kourosh AS, Gilbert E. Placement of high-dose neurotoxins for treatment-resistant rosacea. J Drugs Dermatol. 2023;22(6):605-606. doi:10.36849/JDD.7237

INTRODUCTION

Rosacea is a chronic inflammatory skin condition characterized by facial erythema, telangiectasias, and papulopustular lesions, reported in as high as 22% of the population.1,2 Most patients are diagnosed after the age of 30, with women and Caucasians being the most frequently affected groups.2 Although the pathophysiology of rosacea remains unclear, it appears to be multifactorial in etiology with UV radiation, nutrition, temperature, stress, and immune and neurovascular dysregulation all playing significant roles.3 While not curative, the management of rosacea focuses on limiting these triggers and reducing the duration and intensity of inflammation with topical and oral therapies.4 The majority of these therapies minimally improve the erythematotelangiectatic phenotype of rosacea which may require treatment with lasers or intense pulsed light.5 Botulinum toxin, with doses as high as 100 units, has also been used off-label to reduce erythema and flushing given its anti-inflammatory and inhibitory effects on neurotransmitters and neuropeptides and a resulting hypothetical effect on vasomotor tone. However, this has been met with variable efficacy and unwanted side effects observed in other protocols.1,6,7,8 We present a novel therapeutic protocol that employs high-dose neurotoxins for the treatment of refractory flushing rosacea with improved outcomes and absent side effect profile.

CASE REPORT

A 42-year-old female presented with severe recurrent episodes of erythema and flushing with occasional papulopustular lesions on the bilateral cheeks and forehead (Figure 1A-1C). She failed topical and oral therapies and opted to try off-label neuromodulators. AbobotulinumtoxinA was reconstituted in 1cc of bacteriostatic normal saline and a high-dose microdroplet regimen was initiated. A total of 150-180 units were administered to the affected areas as 3-6 units spaced 1 cm apart. Her symptoms remained well-controlled up to 2-4 months following each treatment (Figure 2A, 2B). Her treatments were eventually spaced to every 6 months after several years of using this dosing protocol (Figure 3).

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