Locking the line of convergence by botulinum toxin type A for the treatment of dynamic forehead wrinkles

Background

Treatment of horizontal forehead lines with botulium toxin type A is a common procedure that helps achieve a youthful and rejuvenated look. Adequate knowledge of the anatomy and an individualized treatment approach is the key to successful treatment outcome.

Aim

To evaluate the cosmetic outcome following treatment of dynamic forehead wrinkles by locking the line of convergence using botulinum toxin type A.

Patients and Methods

Fifty female patients with dynamic forehead wrinkles were included. The line of convergence was identified, and injection points were determined. Patients received injections of botulinum toxin type A in the upper part of the frontalis along the line of convergence. Patients were evaluated before injection and the response was evaluated after 2 weeks and after 3 months of injection.

Results

Post-treatment significant decrease in dynamic wrinkle scale was detected. The distance between the medial and lateral canthi and their corresponding lower brow margins on maximum brow elevation was also significantly decreased after treatment. Meanwhile, the validated brow positioning score revealed no significant change in the resting brow position when pre-and post-treatment scores were compared.

Conclusions

Treating forehead wrinkles by injecting botulinum toxin along the line of convergence is an effective technique that requires less overall amount of toxin, improves the appearance of the wrinkles and minimizes the risk of development of side effects.     

Ａ型肉毒毒素治疗带状疱疹后神经痛疗效评价

目的: 评价皮内注射Ａ型肉毒毒素治疗疱疹后遗神经痛(PHN)的疗效。方法: PHN患者随机分为观察组和对照组,观察组:皮下注射含100单位肉毒素A的生理盐水4mL;对照组:皮下注射曲安奈德注射液+利多卡因注射液 1:1, 4mL。 计算治疗前后痛症状严重程度评分(VAS)。结果: 65例PHN患者,随机分为观察组27例和对照组38例。8周后治疗组和对照组VAS分别为2.72±1.37和4.53±2.20,两组比较差异有统计学意义（P<0.05）, 观察组有效率96.2%,优于对照组76.3%,差异有统计学意义(P<0.05)。 结论: 皮内注射Ａ型肉毒素治疗PHN优于曲安奈德局部封闭。     

Efficacy of hypnosis in the treatment of palmar hyperhidrosis with botulinum toxin type A

BACKGROUND: Injections of botulinum toxin type A are extremely effective in treating palmar hyperhidrosis. The main problem is pain during injections in the palms and pulp of the fingers. Anaesthesia of the hands using Emla and analgesia with an equimolar mixture of oxygen/nitrous oxide are occasionally disappointing. We analysed the value of hypnosis in reducing injection pain. PATIENTS AND METHODS: In a prospective study performed between September 2005 and September 2006, we offered a full session of hypnosis in order to relieve pain for patients presenting troublesome bilateral and palmar hyperhidrosis and requiring treatment by palmar injection of botulinum toxin. At the end of the hypnosis session, patients evaluated their pain on a scale of 0 to 10 and indicated whether or not the injections had been bearable. RESULTS: Of the 15 patients included, 13 underwent a hypnosis session. The mean pain scores following hypnosis were 2.52 and all patients considered their injections bearable. Six patients with a pain score of between 7 and 8 out of 10 during previous injections without analgesia or using Kalinox evaluated their pain as between 1 and 3 following hypnosis. DISCUSSION: Palmar injection of botulinum toxin is increasingly being used for hyperhidrosis patients. In dermatology, access to operating theatres or the presence of a trained anaesthetist is normally extremely difficult, and hypnosis appears to offer an extremely effective method of reducing the pain associated with such injections.     

Efficacy of botulinum toxin A in the treatment of axillary and palmar hyperhidrosis: 10 cases

Axilliary and palmar hyperhidrosis can become a considerable social and psychological handicap. Local treatments are not always effective and endoscopic thoracic sympathectomy is not without side effects. The efficacy of botulinum toxin has recently been demonstrated in axillary and palmar hyperhidrosis. Between June 2001 and June 2002, we treated all the patients presenting with axillary and palmar hyperhidrosis, resistant to classical treatments, with intradermal injections of botulinum toxin A (Dysport). The aim was to assess the interest of this technique at moderate doses, in a prospective, open, controlled study. PATIENTS AND METHODS: The hyperhidrotic areas, revealed by Minor's test, were treated with intradermal injections of 100 U of Dysport in the axilliary form and 250 U in the palmar form. Patients were seen after 1 month and 6 months and underwent a Minor's test, photographic control and they filled-in a questionnaire to measure their satisfaction. RESULTS: Ten patients: 9 women and 1 man aged 19 to 63, were included. Three of them consulted for palmar hyperhidrosis and 7 for auxiliary hyperhidrosis. Within 2 to 7 days, treatment was successful in all patients. The follow-up was of 3 to 12 months. The satisfaction index was comprised between 7/10 and 9/10. The relapse-free interval was of 2 to 9 months. Three patients were given a second injection, which doubled the relapse-free period. Side effects included pain with the palmar injections and moderate headaches.DISCUSSION: This French study confirms the efficacy of botulinum toxin A in the treatment of axillary and palmar hyperhidrosis with relatively low doses (100 U of Dysport per armpit and 250 U per palm). This is an easily reproducible, well tolerated, method without major side effects.     

Pilot study of the safety and efficacy of Myobloc (botulinum toxin type B) for treatment of axillary hyperhidrosis

BACKGROUND: Botulinum toxin type B (BTX-B, Myobloc, San Francisco, CA, USA) was FDA-approved for the treatment of cervical dystonia in December 2000. It has since been used off-label for the treatment of axillary hyperhidrosis. However, there are sparse data in the medical literature evaluating the safety and efficacy of Myobloc (botulinum toxin type B) for this indication. OBJECTIVE: To assess the safety, efficacy and duration of action of Myobloc (botulinum toxin type B) in the treatment of bilateral axillary hyperhidrosis. METHODS: This study was a double-blinded, randomized, pilot study conducted in an outpatient office setting at a private academic medical center beginning in November 2001. Twenty-three male and female volunteers between the ages of 18 and 80 were screened for participation; 20 participants with primary axillary hyperhidrosis were enrolled. Participants were injected subcutaneously with either Myobloc (botulinum toxin type B) (2500 U, or 0.5 ml, per axilla) or 0.5 ml vehicle (100 mM NaCl, 10 mM succinate, and 0.5 mg/ml human albumin) into bilateral axillae. Participants who received placebo were rolled over and received Myobloc (botulinum toxin type B) at subsequent visits. All participants were followed until sweating returned to baseline levels. This trial was initially conceived as a placebo-controlled study; however, owing to the insufficient size of the placebo group, the placebo arm of this trial was dropped during data analysis. The main outcome measures were safety, efficacy, and duration of effect. RESULTS: According to participant assessment of axillary hyperhidrosis improvement (A-HI) and quality of life (A-HQOL) scores and the physician assessment scores, a significant difference was observed in treatment response at Day 30 in the participants receiving Myobloc (botulinum toxin type B) injections. Duration of action ranged from 2.2 to 8.1 months (mean 5.0 months). The adverse event profile included bruising, flu-like symptoms, and dry eyes. CONCLUSION: Myobloc (botulinum toxin type B) proved to be safe and efficacious for the treatment of bilateral axillary hyperhidrosis. More studies are needed to assess the duration of response using different doses of Myobloc (botulinum toxin type B).     

The wrinkles soothing effect on the middle and lower face by intradermal injection of botulinum toxin type A

Background Botulinum toxin type A (BTA) has been used on facial expressive muscles to reduce wrinkles. We assumed that intradermal injection with BTA on the middle and lower face can produce face‐lifting and wrinkles‐soothing effect by promoting collagen synthesis. Methods Nine volunteers were included to undergo intradermal injections of a total dose of 20~25 U BTA into one‐half of the face, and normal saline into the other half as control. Clinical photographs were taken every 4 weeks for 16 weeks, and evaluated by a doctor blinded to the assignments. Patients graded the results of wrinkles elimination on each follow‐up. Skin biopsies were taken before the treatment and 8 weeks after the injection. The specimens were assessed by a pathologist using hematoxylin and eosin stain, elastin stain, Masson trichrome stain and immunohistochemical stain with type I procollagen. Results By photographic documentation, there was no significant face‐lifting effect. However, there was statistical significance in wrinkles reduction on the BTA sides compared to pre‐treatment. Subjectively, six subjects noticed better wrinkles soothing effect on the BTA sides. This effect was noted as early as 4 weeks after injection, and lasted for a minimum 8 weeks. The histologic examination revealed slight neocollagen synthesis by Masson trichrome stain on both sides. Conclusions Based on this pilot study, the face‐lifting effect of intradermal injection with BTA was not conclusive. Interestingly, BTA showed moderate but significant wrinkles‐soothing effect without obvious side effects on the lower face.     

International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit) – part I: upper facial wrinkles

Background Azzalure (Galderma SA) is a newly approved European botulinum neurotoxin type A (BoNT‐A). It is derived from Dysport (Ipsen Pharma), which has a long history of usages in various applications. Azzalure and Dysport are collectively referred to as BoNT‐A (Speywood Unit) and are different from other BoNT‐A preparations. Objective To provide consensus recommendations on the treatment of upper face wrinkles with BoNT‐A (Speywood Unit). Methods The members of the International Board on Botulinum toxin Azzalure (IBBA) convened to develop consensus on the treatment of upper facial wrinkles based on their own extensive experience. Results The consensus recommendations address the general issues regarding treatment and provide specific guidelines on the anatomy, injection points, dose, injection technique and safety precautions concerning each common upper face indication. The recommended final concentration of BoNT‐A (Speywood Unit) is 200 s.U/mL (10 s.U/0.05 mL) after reconstitution. For glabellar lines, the members recommend a total of five injection points with 10 s.U/point. For forehead wrinkles, the members recommend four to six injections into the frontalis with 5–10 s.U/point. For crow’s feet, the members recommend three injections per side with 5–10 s.U/point at the lateral part of the orbicularis oculi. For lateral eyebrow lift , the members recommend one point at each eyebrow tail and an additional one in each side of the frontalis with 5–10 s.U/point. Conclusion This guideline provides a framework for physicians who wish to perform safe and efficacious injection of BoNT‐A (Speywood Unit).     

Efficacy and safety of intralesional 5-fluorouracil in the treatment of keloids

BACKGROUND: The treatment of keloids remains challenging. Cryosurgery and intralesional corticosteroids have been considered as the mainstream of therapy; however, the long-term use of corticosteroids has been found to be associated with serious side effects. Intralesional 5-fluorouracil (5-FU) has only been used in one study for the treatment of hypertrophic scars and keloids, mostly in combination with other treatments. The efficacy of 5-FU as an individual therapeutic agent is unknown. OBJECTIVE: To evaluate the efficacy and safety of intralesional injections of 5-FU in the treatment of small keloid lesions. METHODS: Twenty-four (12 male, 12 female) consecutive patients with keloids of 6 cm or less in their maximum dimension were treated with intralesional injections of 50-150 mg 5-FU per week for a maximum of 16 injections. RESULTS: One third (8/24, 33.3%) of the patients showed more than 75% flattening of the keloid. Three out of 8 patients (with >75% flattening) required less than 16 (13, 13 and 15) injections for achieving the desired response. Overall, about half of the patients showed more than 50% flattening of the treated keloid. A correlation with the duration of keloid was found. Six (54.5%) out of 11 patients with keloids of < or =5 years duration, in contrast to only 2 (15.4%) out of 13 patients with keloids of >5 years duration showed more than 75% flattening (p < 0.05). Side effects included pain (all patients), hyperpigmentation (all patients) and ulceration (1 patient). No difference in peripheral blood count was noted before, during and after the therapy. CONCLUSION: Intralesional 5-FU can be safely used for the management of small keloids of shorter duration.     

A multicenter,double-blind,randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines

BACKGROUND: Botulinum toxin type A (BTX-A) is widely used for facial esthetics but is incompletely studied. OBJECTIVE: This study was conducted to evaluate the efficacy and safety of BTX-A treatment of glabellar lines. METHODS: Patients with moderate to severe glabellar lines at maximum frown received intramuscular injections of 20 U BTX-A (BOTOX, Allergan, Inc, Irvine, Calif) or placebo into 5 glabellar sites. Patients were followed up for 120 days after injection. Outcome measures were physician rating of glabellar line severity at maximum frown and rest, patient assessment of improvement, and vital sign and adverse event monitoring. RESULTS: Two hundred sixty-four patients were enrolled (BTX-A: 203, placebo: 61). There was a significantly greater reduction in glabellar line severity with BTX-A than with placebo (all measures, every follow-up visit; P <.022). The effect was maintained for many patients through day 120. There was a low occurrence (5.4%) of mostly mild blepharoptosis in the BTX-A group. CONCLUSION: BTX-A injections are safe and effective in reducing the severity of glabellar lines.     

International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit) – part II: wrinkles on the middle and lower face,neck and chest

Background Azzalure^® (Galderma SA), a newly approved European botulinum neurotoxin type A (BoNT‐A), is derived from Dysport? (Ipsen Ltd.), which has a 20‐year history of product consistency and has been widely used for various aesthetic and therapeutic applications. Azzalure^® and Dysport? are collectively referred to as BoNT‐A (Speywood Unit) after the unit of their activity, and are distinct from other commercial BoNT‐A preparations. Consensus has been developed for the treatment of upper facial wrinkles with BoNT‐A (Speywood Unit). Objective To provide consensus recommendations on the treatment with BoNT‐A (Speywood Unit) for wrinkles on the middle and lower face, neck and chest region. Methods The members of the International Board on Botulinum toxin Azzalure (IBBA) convened to develop consensus based on their extensive experience. Results The recommended final concentration of BoNT‐A (Speywood Unit) is 200 Speywood Units/ml after reconstitution. The consensus recommendations were provided for nine indications, including lower eyelid wrinkles, bunny lines, drooping nasal tip, perioral wrinkles, masseter hypertrophy, drooping mouth corners, dimpled chin, platysmal bands and décolleté wrinkles. For each indication, anatomy of the region to be treated was discussed, as were potential side‐effects. The consensus recommendations included the number and location of the injection points, dose range of each point and the total injection, as well as specific injection technique. Conclusion These recommendations provide a guideline for physicians who wish to perform safe and efficacious treatment with BoNT‐A (Speywood Unit) on the less commonly treated middle and lower face, neck and chest region.     

A personalized treatment approach of frontalis muscle with botulinum toxin A (Bont-A) related to functional anatomy: case studies

ABSTRACT

Background: The forehead is one of the most frequent sites of botulinum toxin (Bont-A) application. To date, few data are available about the anatomy of the frontalis muscle. Its anatomy is highly heterogeneous in Caucasian people. Consequently, personalized treatments with botulinum toxin-A (Bont-A) are needed to obtain good esthetic results and to reduce side effects. Recently, a study on cadavers found four anatomical shapes of the frontalis muscle, corresponding to four horizontal wrinkle patterns in live patients.

Objective: To perform a personalized, reproducible, and safer treatment with Bont-A of the forehead, by classifying patients according to four specific anatomical shapes of the frontalis muscle related to skin wrinkle patterns during contraction.

Methods: We treated four patients classified according to the four anatomic types (I, II, III, and IV). The patients’ forehead was divided into 21 areas and matched with 4 horizontal wrinkle patterns. Detecting different activities of the muscle in the different areas of the forehead, treatment injections were performed with a different dose, dilution, and at different anatomical layers (intramuscular or intradermal) per point.

Conclusions: We confirmed four different wrinkle patterns after forehead contraction according to the anatomical shape of the frontalis muscle. This allows us to perform a tailored treatment with Bont-A. Nevertheless, some patients with atypical patterns still need “ad hoc” treatment.     

Efficacy and safety of topical calcitriol (1,25-dihydroxyvitamin D3) for the treatment of psoriasis

Summary Plaque-type psoriasis has been successfully treated with topical calcitriol. but there has been no term follow-up study of the safety and efficacy of this calciotropic hormone.
In a single-centre study, patients with plaque or erythrodermic psoriasis were enrolled in a doubleblind, right/left comparison, placebo-controlled study, and received 1·|mUg of calcitriol (15|mUg/g of Vaseline) per day, or a placebo consisting of Vaseline alone. A subset of these patients (n = 22), with at least 25% involvement, applied 0·1 g of calcitriol ointment/50 cm² on an area of from 2500 to 5000 cm².
Of the 84 patients enrolled in the double-blind control study, 96·5% responded to topical calcitriol therapy, compared with 15·5% whose lesions improved with Vaseline alone, after 2 4 months. After completion of the double-blind study. 22 patients applied calcitriol ointment (15 μg/g of Vaseline) to all of their lesions (up to 10 g of calcitriol ointment: 150μg calcitriol lesions showed either excellent or moderate clearing in 90-9% of all cases. The remaining 9·1% of cases showed slight improvement of their lesions. No abnormalities in calcium metabolism were noted in any of the patients using topical calcitriol. None of the patients experienced any local cutaneous side-effects. including six patients who applied calcitriol ointment to the face.
Topical calcitriol is safe and effective for the treatment of psoriasis.     

Efficacy and safety of dapsone gel 5% for the treatment of acne vulgaris in adolescents

Two 12-week, randomized, vehicle-controlled. double-blinded pivotal studies and a 12-month. long-term, open-label, noncomparative safety study were conducted to evaluate the efficacy and safety of dapsone gel 5% in patients with acne vulgaris. Of 3516 participants enrolled in the 3 trials, 1306 participants (37%) were adolescents aged 12 to 15 years and comprised the subgroup reported here. Participants randomly were assigned to twice-daily treatment with dapsone gel (n=578) or vehicle gel (n=547) in the pivotal studies and received open-label treatment with dapsone gel in the long-term safety study (n=181). In the pivotal studies, success based on achieving a Global Acne Assessment Score (GAAS) of 0 (none) or 1 (minimal) at week 12 was significantly greater for the dapsone gel-treated adolescent participants (40.1%; 232/578) compared with the vehicle gel-treated adolescent participants (28.2%; 154/547) (P<.001). Treatment with dapsone gel in adolescents also resulted in clinically meaningful improvements in acne lesion counts by week 12 in the pivotal studies and for up to 12 months in the long-term safety study. The incidence of adverse events, including application-site events, was low and similar between treatment groups in the pivotal studies and was similarly low in the long-term safety study. Results from the large number of adolescent participants in these 3 studies show that dapsone gel is an effective and safe topical therapy for the treatment of acne vulgaris in adolescents aged 12 to 15 years for up to 12 months.     

Efficacy and safety of oxymetazoline for the treatment of rosacea: A meta-analysis

Background

Since there is currently no conclusion on the efficacy and adverse effects of oxymetazoline, this meta-analysis attempts to explore its efficacy and adverse events, so as to provide guidance for clinical medication.

Methods

We searched PubMed, Embase, and Cochrane Library from the establishment of the database to May 2021. We included studies that patients were randomly assigned to receive oxymetazoline or vehicle, and we excluded duplicate publications, research without full text, incomplete information or inability to conduct data extraction, animal experiments, reviews, and systematic reviews. STATA 15.1 was used to analyze the data.

Results

The pooled results show that the 3 (RR = 1.76, 95% CI: 1.53–2.03), 6 (RR = 1.71, 95% CI: 1.47–2.00), 9 (RR = 1.63, 95% CI: 1.40–1.90), 12 (RR = 1.41, 95% CI: 1.18–1.67) -hours CEA success rate and the 3 (RR = 1.65, 95% CI: 1.34–2.03), 6 (RR = 1.75, 95% CI: 1.43–2.14), 9 (RR = 1.63, 95% CI: 1.33–2.00), 12 (RR = 1.78, 95% CI: 1.45–2.18) -hours SSA success rate after oxymetazoline treatment for rosacea is significantly higher than that of vehicle. Additionally, the pooled results show that the incidence of TEAEs after treatment with oxymetazoline is significantly higher than that of vehicle (RR = 1.34, 95% CI: 1.10–1.2). However, our analysis of specific adverse events found that the oxymetazoline group was only significantly higher than the vehicle group in the incidence of application-site dermatitis (RR = 8.91, 95% CI: 1.76–45.23), and there was no statistical significance in the difference in the incidence of other adverse events.

Conclusion

Oxymetazoline is effective and can be selected for the treatment of persistent facial erythema of rosacea. Additionally, application-site dermatitis was the most important one.