Persistent Facial Blanching after Botulinum Toxin Injection

Abstract

We report the case of a 38-year-old male patient who presented with blanching of the face after strenuous exercise or physical exertion. The symptoms regressed in a relaxed state. Three years before presentation, he underwent botulinum toxin injections in the affected areas of the face. Facial blanching is a rare side effect of botulinum toxin injection. The postulated pathophysiology involves different transmitters mainly acetylcholine as well as co-transmitters implicated in vasodilation. Usually, facial blanching resolves shortly after waning of the botulinum toxin. However, in our case, the symptoms persisted for a longer time. Till date, therapy options for post-botulinum facial blanching are lacking, mainly due to the temporary aspect of the disease.

Fragmented Facial Flushing: A Quiz

“…In addition to the more common adverse effects reported, blanching after botulinum toxin injections has also been reported as a rare adverse effect of the medication with an unclear mechanism of action (1)(2)(3)(4)(5). Although controversial, it has been hypothesised that botulinum toxin blocks the vasodilatory effect of acetylcholine, other neurotransmitters, or co-transmitters including prostaglandins, endotheliumderived hyperpolarising factor, and nitric oxide, thereby inhibiting physiologic flushing with exercise and leading to the perceived visualized blanching noted at injection sites (3)(4)(5).…”