Body Language

A double-blind comparison of onabotulinumtoxina (Botox) and topiramate (Topamax) for the prophylactic treatment of chronic migraine: a pilot study.
Mathew NT, Jaffri SF. Headache, 2009 Nov-Dec;49(10):1466-78.

There is a need for effective prophylactic therapy for chronic migraine (CM) that has minimal side effects. The objective of this single-centre, double blind study was to compare the efficacy and safety of onabotulinumtoxinA (Botox), and topiramate (Topamax) prophylactic treatment in patients with CM.

Botox or placebo saline injection was administered at baseline and month three only, while Topamax oral treatment or oral placebo was continued to the end of the study.

The study duration was approximately 10.5 months, including a four-week screening period and a two-week optional final safety visit. Follow-up visits for patient assessments occurred at months one, three, six, and nine.

Of the 60 patients taking part, 36 completed the study. In the Topamax group, 24.1% discontinued the study because of treatment-related adverse events versus 7.7% in the Botox group.

Between 68%–83% of patients for both groups reported at least a slight improvement in migraine. Most patients in both groups reported moderate to marked improvements at all time points.

No significant between-group differences were observed. At month nine, 40.9% and 42.9% of patients in the Botox and Topamax groups respectively reported 50% or more reduction in headache/migraine days.

Results showed OnabotulinumtoxinA and topiramate demonstrated similar efficacy in the prophylactic treatment of CM. Patients receiving Botox had fewer adverse events and discontinuations.

This is an interesting study on a popular use of botulinum toxins. Patients must be consulted that the procedure is likely to reduce the severity and frequency of their migraines but that it cannot be expected to eliminate them.

Routine use of Xeomin in patients previously treated with Botox: long term results.
Dressler D. Eur J Neurol. 2009 Dec;16 Suppl 2:2-5.

The potential of Xeomin can only be assessed when it is used outside of study design restrictions in an independent setting, in off-label indications and during continued use.

A total of 263 patients took part in this study, with indications comprising dystonia, spasticity, hemifacial spasm and re-innervation synkinesias, hyperhidrosis and hypersalivation.

They were previously treated with Botox for at least one year and were converted in a blinded fashion to Xeomin using a 1:1 conversion ratio and identical treatment parameters.

Therapeutic outcome and adverse effects were monitored by neurological examination and structuralised interviews. In 223 patients, except those with axillary hyperhidrosis, Xeomin was used continuously for three years.

There were no subjective or objective differences between Botox and Xeomin treatments regarding onset latency, duration of their therapeutic effects and their adverse effect profiles.

The study concluded that Xeomin can be used safely in doses of up to 840 MU.

Even when applied in high doses, it did not produce secondary therapy failure. There were no diffusion differences between Botox and Xeomin. Using a conversion ratio of 1:1, Xeomin and Botox can be exchanged in a continued treatment.

Experience with Xeomin is still in the early phases and more studies may be required to increase confidence among practitioners.

Hyaluronic acid filler injections with a 31-gauge insulin syringe.
Lim AC. Australas J Dermatol. 2010 Feb;51(1):74-5.

Hyaluronic acid gel is a commonly-used soft tissue filler in cosmetic dermatology. Hyaluronic acid fillers are packaged in proprietary luer-lock syringes that can be injected using a 30-gauge, 27-gauge or larger diameter needle depending on the consistency of the gel.

The use of a 31-gauge insulin syringe for filler injections can potentially enhance the injection process through more accurate product delivery and placement.

This has the potential to produce a more balanced and symmetrical outcome for patients. Additional benefits include less injection pain, less bleeding or bruising and higher levels of patient satisfaction.

Dermafillers can be a painful treatment for some patients, even with topical EMLA anaesthetic cream. Small volume fllers injected with 30-gauge needles are reasonably tolerated but deeper fillers injected with 27-gauge or above needles often lead to discomfort.

The authors describe a useful technical tip which may be used in the minority of patients who cannot tolerate deeper dermafillers.


Effect of multisyringe hyaluronic acid facial rejuvenation on perceived age.
Taub AF, Sarnoff D, Gold M, Jacob C. Dermatol Surg. 2010 Jan 19. [Epub ahead of print]

The objective of aesthetic treatments is to create a more youthful appearance. Most injectable fillers are indicated for the reduction of nasolabial folds, but the current aesthetic movement is toward volume replacement in multiple areas, known as global fillers or a liquid face-lift.

The aim of the study was to quantify the degree of perceived age reduction from multisyringe hyaluronic acid treatment.
Ten women were treated with 6–8ml of hyaluronic acid. Exclusion criteria were no laser or hyaluronic acid fillers for six months and no semi-permanent fillers for one year. High-resolution photographs were taken before treatment and two and four weeks afterwards. Three blinded dermatologists rated patients’ ages before and after from photographs.

The dermatologists reported an average of 6.1–7.3 years of reduction in apparent age at two and four weeks respectively. The patients perceived a decrease in apparent age of 7.8 and 9 years. It was concluded that multisyringe injection of hyaluronic acid filler into the ageing face results in a reduction of apparent age from 6.1 to 9 years after 2–4 weeks.

The quantity of filler injected varies with the experience of the practitioner and patient expectation. Practitioners can use this study to empower patients and treat them with an increasing volume of filler volume as appropriate.

Reviewing the peer press is Rohit Kotnis (Lon), Dip SEM (Ed). Rohit is an advanced tutor at Dermis Deep, Birmingham and a member of the Body Language editorial panel