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Off-Label Pearl

Dr. Ted Rosen reviews a case study suggesting dermal microinjections of botulinum toxin A (BTX-A) can improve facial flushing and erythema in patients with refractory rosacea.

Botulinum Toxin Microdroplets for Refractory Rosacea Erythema

By Ted Rosen, MD, FAAD
Editor-in-Chief 

What would you do if a rosacea patient had persistent severe facial erythema and telangiectasia despite the following treatments:

  • Multiple pulsed dye laser treatments 
  • Various topical therapies, including azelaic acid 15% gel and metronidazole cream 0.75% 
  • Systemic therapies, including isotretinoin 20 mg daily, spironolactone 25 mg daily, and doxycycline 100 mg twice daily 

An on-label management tool might be the use of an alpha-2 adrenergic receptor agonist to induce vasoconstriction. Examples include brimonidine 0.33% gel and oxymetazoline 1% cream. 

However, these agents may fail, may induce an undesirable “ghost-like” cutaneous whiteness, and are somewhat short-lived in duration of effect.

The authors of the cited paper had an excellent and long-lasting result with intradermal microdroplet injections of BTX-A. They first injected 20 U total and then 4 weeks later injected 15 U total into the affected areas. The microdroplets consisted of 0.05 cc 1.25 IU/0.1 mL diluted BTX-A. 

The patient’s cosmetically distressing erythema and intermittent flushing was completely controlled through 16 weeks of follow-up. 

I can’t wait to try this!

To Read More: 

Babadjouni A, et al. Turning Down the Fire: The Role of Botulinum Toxin Microdroplets in Refractory Rosacea Erythema. SKIN The Journal of Cutaneous Medicine. 2022; 6(5), 437–440. doi: /10.25251/skin.6.5.16