Treating rosacea with botulinum toxin type A
Dr Rachael Eckel discusses how toxins can be used to reduce facial flushing and erythema
The etiology of rosacea is multifactorial; neurovascular dysregulation, inflammation, and hyperseborrhea all contribute to disease pathogenesis. Novel treatment techniques with botulinum toxin type A (BoNTA) are appealing. The neuromodulator comprehensively targets the three cardinal pillars of disease causation, reducing facial flushing and erythema.
Q. How does it work for treating Rosacea?
By targeting specific neurotransmitters (seretonin) and ion channels (transient receptor potential vanilloid 1 through 4) involved in disease pathology, BoNTA imparts benefit to the neuroinflammatory component of rosacea. It has also been shown to stabilise vascular hyperactivity, which may be tangential to its effect on minimising pore size and sebaceous gland output.
Q. What evidence exists?
For over 15 years BoNTA has been employed for its cosmetic benefits, yet we are only now beginning to investigate its potential therapeutic power. A simple search on PubMed will reveal a mere 4 studies describing the use of neurotoxins to remedy rosacea. The largest and most comprehensive of these publications (Dermatol Surg 2015 Jan), assessed erythema scores amongst rosacea subjects, following injections with BoNTA. Compared to baseline, a 45% mean erythema improvement occurred at the three monthly follow up.
This statistically significant result allowed the authors to conclude that BoNTA is an effective therapeutic option for the treatment of facial erythema. This innovative approach must however be explored further with larger, randomised, blinded, placebo-controlled studies.
Q. Does the treatment work on all patients with rosacea?
In my clinical experience the treatment works well overall. However not everyone with rosacea will achieve success with BoNTA. Response appears to be related to disease subtype, which is important to assess during the initial consultation. Phymatous and erythematotelangiectatic typologies typically confer more favourable results.
Q. Can you tell us more about the technique?
Treatment of the face is guided by anatomical affliction with erythema. Each area should be subdivided and injected with four to six intradermal blebs of BoNTA, 1cm apart.
When reconstituting the neuromodulator I use a dilution of 7mls of saline per 100 units of incobotulinumtoxinA or onabotulinumtoxinA (label dosing for both requires 2.5 mls). A typical patient will require 10 to 15 units per area of with these products, or 20 to 30 units of abobotulinumtoxinA. These figures can be further adjusted depending on patient gender and size of the treated region.
Endeavor to cover all apposite areas at a financially reasonable price.
Q. Is this a safe method of treatment for rosacea?
There have been no adverse events documented in clinical trials, but injection skill is seminal. To avoid unwanted muscle paralysis, product placement must remain superficial. It is also worth remembering that this is currently an off-label use of BoNTA and patients should be counseled accordingly.
Q. When are benefits seen and is maintenance needed?
Four weeks post-injection patients notice results, lasting between four and six months. Treatment with BoNTA must however be replicated lifelong, as rosacea is a chronic dermatosis. This can nonetheless be modified to suit disease aggression and relapse rate. It is postulated that repeated treatments will impart a cumulative effect on suppressing the neuroinflammatory process, thereby reducing injection frequency over time.
Q. Should it be used in isolation?
Combination therapy yields optimum results for rosacea. Physicians should treat a disease using the standard of care, and explore new areas that are safe and scientifically tested. In this manner we can expand therapeutic options and improve our patients’ quality of life.
Q. Can you tell us how you incorporate this treatment in your practice?
I adopt a holistic approach to ameliorating rosacea. An important preliminary measure is educating patients about recognising and avoiding triggers. I also prescribe a ZO Skin Health topical programme focusing on sebum reduction, barrier restoration, inflammatory control, sun protection, and keratinocyte maturation cycle enhancement. Laser therapy can be appropriate when correcting texture (CO2 fractionated laser) or improving fixed erythema (flashlamp pumped dye laser). In patients who require the latter, I supplement BoNTA to maintain results.
Should lasers to correct erythema not be permissible, due to oral isotretinoin treatment or long-term microdose therapy, neuromodulators can be a favourable alternative. They are also a valuable adjunct in those who flush and who cannot afford the social downtime associated with lasers or topical therapy. BoNTA is particularly effective at managing rhinophyma, especially after surgical debulking of the tissue.
Dr Rachael Eckel is a Cosmetic Dermatologist, board certified by the American Board of Aesthetic Medicine, USA. A native of Trinidad and Tobago, Dr Eckel completed her medical training at the prestigious Royal College of Surgeons in Ireland.