A Pilot Study to Evaluate the Efficacy and Safety of Treatment with Botulinum Toxin in Patients with Recalcitrant and Persistent Erythematotelangiectatic Rosacea

Abstract

Background: There are few pharmacologic options to reduce erythema and flushing in patients with recalcitrant erythematotelangiectatic rosacea (ETR). We previously reported two cases of refractory flushing and erythema of rosacea that were successfully treated with intradermal botulinum toxin injection, and additional research is needed to prove the efficacy and safety of this treatment. Objective: To report the efficacy and safety of botulinum toxin injection as an aid in persistent erythema of rosacea patients. Methods: A total of 20 Korean patients with recalcitrant ETR were enrolled to receive treatment by injection of botulinum toxin. Patients received one treatment of intradermal botulinum toxin injection and were assessed 1, 2, 4, and 8 weeks after treatment. The severity of erythema and telangiectasia was investigated by a non-treating physician, and the Erythema Index (EI) was assessed by mexameter at each visit. Patient satisfaction and any adverse events were also assessed at each visit. Results: 17 patients completed all follow-up visits and were included in the analysis. Intradermal injection of botulinum toxin significantly reduced erythema severity and EI in ETR patients. Patients reported a satisfaction score of 2.94±0.56 at 8 weeks after treatment. Except for three patients who discontinued the study early due to inconvenience of facial muscle paralysis, 17 patients participating in the final analysis did not report side effects except injection pain at the time of the procedure. Conclusion: Intradermal injection of botulinum toxin can be used as an effective and relatively safe adjuvant agent for recalcitrant and persistent erythema of ETR patients. (Ann Dermatol 30(6) 688∼693, 2018

Use of Botulinum Toxin in Treating Rosacea: A Systematic Review

“…They did not follow up possibly due to the dissatisfaction of treatment effects, or potential concern about adverse effects. In Park et al study, 31 facial muscle paralysis was reported in three patients, and resolved without any special treatment. This was possibly due to treatment volume and injection depth.…”

“…In Bloom et al study with 25 participants, 28 one withdrew, and nine had inconsistent follow-up visits, the reason for which was not provided. In Park et al study with 20 Korean patients, 31 three patients reported undesired paralysis of facial muscles and stopped participating the study, although their symptoms were resolved without any special treatment. In Kim et al study with 24 participants, 33 one patient was excluded because of protocol violation, intake of muscle relaxant for ankle sprain.…”

“…Nine studies were included in this systematic review (Table 1). 13,[27][28][29][30][31][32][33][34] These studies were published between 2012 and 2020. Two studies were RCTs.…”

“…Some researchers only reviewed the possible mechanisms in previous literatures, and identified some key substances, such as acetylcholine, 27 vasoactive intestinal polypeptide, vascular endothelial growth factor, substance P, calcitonin gene-related peptide, and transient receptor potential channel vanilloid family member 1 receptors. 27 , 31 , 33 …”

“…27 Gradually, previously reported scales, such as Rosacea Clinical Scorecard (RCS), 30,41 Global Aesthetic Improvement Scale (GAIS), 33,42 were used to assess the severity of rosacea symptoms. Mexameter MX18 31 , dermoscopy, 32 and a combination corneometer/mexameter/ reviscometer/sebumeter device 33 were used to evaluate therapeutic responses. State Self-Esteem Scale (SSES) 30,43 was used to assess subjects' self-esteem.…”