Botox Therapy for Ischemic Digits

The Use of Digital Hand Sympathectomies for the Treatment of Ischemia and Pain Following Inadvertent Corticosteroid Injection of the Radial Artery: Two Case Reports

Osteoarthritis of the carpometacarpal (CMC) joint of the thumb is commonly treated with intraarticular corticosteroid injections in clinic. In this case report, we present 2 patients who experienced immediate pain, pallor, and discoloration of their fingers distal to the site of attempted injection of the CMC joint of the thumb. It is believed that this occurred due to inadvertent injection of the dorsal branch of the radial artery as it branches to join both the superficial and deep palmar arches. This caused vasospasm and vasoocclusion leading to subsequent ischemia. To relieve symptomatic pain and prevent ischemic necrosis, both patients underwent sympathectomies of the radial and ulnar arteries and of the common palmar digital arteries. Both patients experienced relief of their pain and reperfusion of their hand and digits.

Efficacy of adipose stromal cells-enriched high-density fat graft combined with BTX-A for Raynaud's phenomenon: a prospective cohort study

BACKGROUND

Conventional treatments for Raynaud's phenomenon (RP) often show limited effectiveness due to their inability to address both vascular and inflammatory aspects. This study evaluates the combination of high-density fat grafting (HDFG) with botulinum toxin A (BTX-A) for treating RP.

METHODS

Eleven patients with 20 affected hands diagnosed with RP were recruited and randomly assigned to receive either HDFG combined with BTX-A (intervention group, n = 11) or HDFG alone (control group, n = 9). Efficacy was assessed using Visual Analog Scale (VAS) pain scores and McCabe Cold Sensitivity Scores, along with finger ulcer healing time and infrared thermal imaging to evaluate blood perfusion improvements.

RESULTS

The HDFG-BTX group showed significant improvements in hand symptoms. VAS pain scores decreased from a pre-treatment mean of 5.33 to 0.84 post-treatment (mean reduction of 4.49, p = 0.018), indicating effective pain relief. McCabe scores improved from 272.73 to 75.00 (mean reduction of 197.73, p = 0.001), demonstrating reduced cold sensitivity. Ulcer healing time was shorter in the HDFG-BTX group (14.25 days) compared to HDFG alone (25.6 days, p < 0.001), highlighting faster recovery. Infrared imaging indicated significant enhancements in blood perfusion.

CONCLUSION

HDFG combined with BTX-A is a reliable and beneficial intervention for RP, leading to high patient satisfaction.

A systematic review of botulinum toxin as a treatment for Raynaud's disease secondary to scleroderma

Raynaud's phenomenon (RP) is a vasospastic disorder that affects the small blood vessels in the extremities such as the hands, feet, fingers or toes. It is a debilitating condition that can severely impact the patient's quality of life. Botulinum toxin (BTX) has been examined as a treatment option for RP, but its effect has been inconclusive. A systematic review has been conducted to determine the current evidence of BTX as a treatment for RP secondary to scleroderma. Major clinical databases Medline, Embase (via Ovid), the Cochrane Central Library, ClinicalTrials.gov, EU Clinical Trials Register and the ISRCTN registry were systematically searched from its inception to 27 November 2023 for studies describing BTX and RP. Standard mean differences of Quick-DASH scores, visual analogue scale pain (VAS-P) score and Raynaud's condition score (RCS) are reported with BTX treatment with a random-effect model. A total of 890 entries were retrieved. Of these, 19 met the inclusion criteria, and all studies were included for analysis. There was a significant effect (p = 0.03) with Quick-DASH score and VAS-P score (p < 0.00001) but a non-significant effect (p = 0.37) with RCS. BTX is a therapeutic option in the treatment of RP secondary to scleroderma; however, the evidence published so far is not sufficient to credit it as a revolutionary first line treatment. More research is needed to establish dosing, techniques and core outcome measures for BTX in RP.

Radial cortex transverse distraction help to treat the Raynaud's phenomenon

Raynaud's phenomenon is a condition that causing vasospasm of the digital extremities and have a great influence on the quality of patients life. Distraction osteogenesis is accompanied with vascularization and regeneration of surrounding soft tissues. There have been no previous reports of using radial cortex transverse distraction for the treatment of RP. Since January 2019 to January 2023, 6 patients with RP accepted radial cortex transverse distraction. They were failed to conventional treatment for at least six months before the surgery. All the patients were followed-up over 1 year. The bone cortex healed without osteomyelitis or fractures. The ulcer of finger healed in one month. The pain and skin pale released after the surgery. The VAS score declined from 6 to 2 and the finger SpO2 improved. Radial cortex transverse distraction facilitated finger ulcer healing, salvage the hand and improved Raynaud symptoms. These findings suggest that radial cortex transverse distraction may be an effective procedure to treat the Raynaud's phenomenon.Level of Evidence II Therapeutic study.

Botulinum Toxin for the Treatment of Raynaud's Conditions of the Hand: Clinical Practice Updates and Future Directions

Raynaud's conditions of the hand, referred to commonly as Raynaud's phenomenon, both primary and secondary, represents a spectrum of disorders affecting the digits, characterised by recurrent episodes of vasospasm that result in a triad of symptoms: pain, pallor, and cyanosis. Various therapies, ranging from conservative hand therapy techniques to surgical sympathectomy, have been explored with inconsistent results. Recently, the local administration of botulinum toxin type-A (BTX-A) has re-emerged as a treatment option for this condition. This review delves into the mechanistic pathways of BTX-A therapy, optimal dosing concentrations, administration techniques, and its safety profile. A critical analysis of published studies to date demonstrates varied clinical efficacy of BTX-A in Raynaud's conditions based on patient-reported outcome measures and objective measures of outcomes assessment. Thus, in order to accurately assess the clinical effectiveness of BTX-A in future robust studies, this review emphasises the importance of streamlining patient selection to minimise heterogeneity in disease severity, optimising recruitment to ensure adequate statistical power, and establishing sensitive outcome measures to monitor response and discern treatment efficacy. Additionally, addressing concerns such as minimising antibody resistance, extending the duration of treatment effects on tissues, and exploring new modalities to assess hand perfusion will be focal points for future research and BTX-A drug development.

Radial Artery Reconstruction After Iatrogenic Cannulation-Related Occlusion: A Case Report

A 59-year-old male, with a history of angiogram via the left radial artery during the workup for multi-trauma, presented to the hand clinic with a 14-day history of progressive critical ischemia in the left thumb and index finger, along with dry gangrene of the distal index fingertip. Radial artery occlusion was confirmed on imaging. The patient underwent radial artery thrombectomy, arterial reconstruction with vein graft, and amputation of the index fingertip. Postoperatively, perfusion to the thumb and index finger was restored, resulting in the resolution of associated pain and hypersensitivity. This case demonstrates the delayed presentation of ischemia following radial artery cannulation, which was successfully managed with radial artery thrombectomy and a saphenous vein graft.

Part II: The treatment of primary and secondary Raynaud's phenomenon

Raynaud phenomenon (RP) presents with either primary or secondary disease, and both have the potential to negatively impact patient quality of life. First-line management of RP should include lifestyle modifications in all patients. Some patients with primary RP and most with secondary RP require pharmacologic therapies, which may include calcium channel blockers, topical nitrates, phosphodiesterase 5 inhibitors, or endothelin antagonists. Additional approaches to treatment for those with signs of critical ischemia or those who fail pharmacologic therapy include botulinum toxin injection and digital sympathectomy. Herein, we describe in detail the treatment options for patients with RP as well as provide treatment algorithms for each RP subtype.

The Use of Botulinum Toxin in Raynaud Phenomenon: A Comprehensive Literature Review

BACKGROUND

Raynaud phenomenon (RP) is a vasospastic condition of the digits that can be primary or secondary to systemic disease. Symptoms are triggered by cold or stress and can cause pain and skin color changes. The chronic ischemia may lead to necrosis, ulceration, and amputation. There are no Food and Drug Administration-approved treatments and cases refractory to pharmacologic and surgical treatments are difficult to control. Local botulinum toxin injections have been increasingly used in the treatment of Raynaud disease and have shown promising results.

AIM OF THE STUDY

To examine the outcomes, techniques, and complications of botulinum toxin use for the treatment of Raynaud disease.

METHODS

The PubMed database was queried using "botulinum toxin" AND "Raynaud phenomenon" as title key words. Preferred reporting items for systematic reviews and meta-analysis criteria were used. Additional articles were selected while reviewing the references of the articles from PubMed. No time restrictions were followed. Articles of all languages were included. Articles were analyzed for study type, demographics, diagnosis/inclusion criteria, treatment methods, outcome measures, length of follow-up, results, and complications. A positive outcome was defined as subjective improvement in symptoms and/or improvement in the outcome measures. A poor outcome was defined as harm done to the patient by the injection that would not have occurred otherwise.

RESULTS

Forty-two clinical studies describing the use of botulinum toxin for Raynaud's phenomenon were found. A total of 425 patients with primary or secondary Raynaud's were treated, with ages ranging from 14 to 91 years. There were 342 women and 81 men, with a female-to-male ratio of 38:9. Outcomes were positive in 96.2% of patients. There were 14.2% of the studies that reported 3.5% of all patients showing no subjective improvement. A single study reported a poor outcome for 1 patient. There were 40.5% of the studies that reported complications, affecting 20.2% of all patients. The most frequently reported complication was transient hand weakness, affecting 44.2% of patients with complications and 8.9% of total patients. Weakness resolved in hours to months after injection. Pain at the injection site lasting minutes to days was reported in 40.7% of patients with complications, and 8.2% of total patients.

CONCLUSIONS

Botulinum toxin treatment for RP is effective. Complications are minor and self-limiting.

Distal Bypass to the Deep Palmar Arch for Treatment of a Unique Presentation of Digital Ischemia

Radial artery occlusion leading to hand ischemia is a serious problem that may require prompt surgical intervention. Due to the rarity of these events, consensus on the most effective surgical approach has not yet been reached. There is even scarce literature on appropriate management of symptomatic radial occlusion in patients with a congenital variation in hand vasculature. We report on a case of a 38-year-old woman with radial artery occlusion who underwent a successful distal radial artery bypass to the deep palmar arch due to a diminutive ulnar artery and the absence of a superficial palmar arch. Radial artery bypass to the deep palmar arch using a reversed vein graft is a viable treatment option for preventing further digital ischemia or necrosis in patients with a compromised vasculature of the hand.

Efficacy and Safety of Botulinum Toxin in Adults with Raynaud's Phenomenon Secondary to Systemic Sclerosis: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Study

OBJECTIVE

To determine whether a single session of botulinum toxin type A (BTA) injections into both hands more effectively decreases the frequency of systemic sclerosis-associated Raynaud's phenomenon (SSc-RP) episodes than placebo.

METHODS

This multicenter, randomized, double-blind, placebo-controlled, parallel-group phase III trial in patients with SSc-RP assessed the effect of 50-unit BTA or placebo injections into the palms of both hands around each neurovascular bundle during 1 session in winter. The primary end point was the between-group difference in the median change in the number of RP episodes from baseline (day 0) to 4 weeks postinjection. Values between the groups were compared with the Wilcoxon rank-sum test.

RESULTS

The intent-to-treat analysis included 46 BTA-treated patients and 44 placebo recipients. At 4 weeks after assigned treatment injections, the median number of daily RP episodes decreased comparably in the BTA and placebo groups (median change -1 episode/day [interquartile range (IQR) -1.5, 0 episodes/day] and -1 episode/day [IQR -2.5, 0 episodes/day], respectively) (P = 0.77 versus placebo). Moreover, change in Raynaud's Condition Score, quality of life assessed by Health Assessment Questionnaire disability index, and hand function assessed by shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Cochin Hand Function Scale from baseline to follow-up weeks 4, 12, and 24 did not differ significantly between groups. The BTA group experienced transient hand muscle weakness significantly more frequently (P = 0.003).

CONCLUSION

Neither the primary nor secondary end points were reached, and our results do not support any beneficial effect of palmar BTA injections to treat SSc-RP.

Peripheral Artery Bypass Graft for the Treatment of Ischemic Ulcer or Severe Pain of Hand in Connective Tissue Diseases

ABSTRACT

Chronic ischemia of the hands and feet is a rare medical condition that requires surgical revascularization. In particular, digital ischemia resulting from connective tissue diseases (CTDs) is among the most important manifestations that negatively affect patients' quality of life. Here, we describe a bypass graft technique for treating digital ischemia. This study aimed to share the considerable benefits of surgical intervention for CTD and present a treatment algorithm. From 2009 to 2020, bypass graft surgery was performed on 10 patients with CTD to relieve their ischemic symptoms or ulceration. Preoperative angiography was performed, and blood distribution patterns were analyzed in detail. Based on the angiographic 4-level analysis, bypass graft surgeries were performed accordingly. The postoperative follow-up was 15 to 72 months. Pain in the hands that underwent the bypass graft surgery improved immediately after surgery. All ulcerations healed and the mean time recorded for ulceration healing was 45.7 days. Here, we propose an appropriate surgical treatment algorithm for managing CTD using arterial bypass graft surgery, and its positive long-term results demonstrate that it is an appropriate option for treating digital ischemia. In conclusion, strict measures with precise preoperative planning can provide satisfactory long-term results in patients with CTD.

Simultaneous bilateral distal venous arterialization between redial artery and cephalic vein in dorsal hand for Raynaud's phenomenon in both hands: A case report

Raynaud's phenomenon (RP) is characterized by episodic vasospasm in peripheral vessels and ischemia of the fingers. Venous arterialization is thought to induce neovascularization and increased oxygen tension. In this report, we describe a patient with RP in the fingers of both hands in whom venous arterialization achieved an acceptable result in both hands. The patient was a 62-year-old woman with a 10-year history of worsening pain and cold sensation in the tips of the index, middle, ring, and little fingers on both sides. The venous arterialization procedure was performed on both hands simultaneously at the level of the anatomical snuff box between radial artery and cephalic vein in dorsal hand. There was no need for valvectomy in the level of hands. To prevent development of the steal phenomenon in the arterialized veins, the superficial basilic and median veins of the forearm were ligated via 1 cm skin incisions. The pain and cold sensation in the fingertips of both hands remained decreased, and the nonhealing ulcers on the fingertips healed without the need for amputation. The observation period was 14 months, and the surface temperature of the fingers was increased after venous arterialization, as was the temperature of the palm and forearm. There was no problem when administering intravenous infusion into the forearm on either side postoperatively. The case showed venous arterialization was effective for RP without increasing intravenous pressure in the affected limb, and further investigation is necessary.

Botulinum Toxin A for the Treatment of Sympathomimetic Pressor-Induced Digital Hand Ischemia in the Critically Ill Intensive Care Unit Patient

Vasopressor-induced ischemia of the hand, while relatively rare, is a severe complication in critically ill intensive care unit (ICU) patients requiring high concentrations of sympathomimetic pressors and often results in digit necrosis and amputation. Currently, there are no widely accepted approaches for treating this cause of peripheral digital ischemia. Case reports have demonstrated that reducing the concentration of vasopressors that patients are given may reverse the progression of ischemic events prior to necrosis. While this approach is at odds with the principle of "life over limb," it demonstrates that digit necrosis can be reversed, resulting in improved outcomes. Here, we present a therapeutic strategy for treating digital limb ischemia in the septic ICU patient without the need to lower systemic vasopressor dose by using locally injected botulinum toxin A into ischemic hands.

Off-Label Use of Botulinum Toxin in Dermatology—Current State of the Art

Botulinum toxin (BoNT) is a neurotoxin produced by the Clostridium botulinum bacteria. Among seven different isoforms, only BoNT-A and BoNT-B are commercially used. Currently, botulinum toxin has been indicated by the U.S. Food and Drug Administration in several disorders, among others: chronic migraine, hyperhidrosis, urinary incontinence from detrusor overactivity, or cosmetics. However, there are numerous promising reports based on off-label BTX usage, indicating its potential effectiveness in other diseases, which remains unknown to many. Among them, dermatological conditions, such as rosacea, annal fissure, Raynaud phenomenon, hypertrophic scars and keloids, and also hidradenitis suppurativa, are currently being investigated. This article aims to provide a comprehensive update on the off-label use of botulinum toxin in dermatology, based on an analysis and summary of the published literature.

The efficacy of Botulinum toxin A in the treatment of Raynaud's phenomenon in systemic sclerosis: A randomized self-controlled trial

The current conservative and surgical treatments are not fully effective and have complications for Raynaud's phenomenon (RP) secondary to systemic sclerosis (SSc). Botulinum toxin A (BTX-A) can be used to manage RP, but the literature mostly includes case reports and case series. To perform a randomized controlled trial to explore the efficacy of BTX-A in the treatment of RP secondary to SSc. Sixteen patients with RP secondary to SSc were recruited. One hand was randomly included in the BTX-A group and the other as control. Both hands were tested before treatment and 4 weeks later using qualitative and quantitative dermatoscopic assessments and the cold water test. Reynolds score (from 6.7 ± 4.0 to 2.9 ± 3.7, P < 0.001), T_base (from 25.8 ± 3.0°C to 27.9 ± 2.1°C, P = 0.031) and T_change (from 2.1 ± 1.2°C to 4.5 ± 2.1°C, P < 0.001) in the experimental group were improved, while there were no improvements in T_base and T_change in the control group. In the experimental group, the sum of the six dermoscopic parameters was improved after treatment (from 4.00 (3.00,5.75) to 3.00 (2.00,5.00), P = 0.002); the nailfold capillary pattern staging was also improved (from 2.00 (2.00,3.00) to 2.00 (1.00,3.00), P = 0.004). There were no improvements in the dermoscopic assessment in the control group. None of the patients reported adverse reactions such as infection, hematoma, hand muscle weakness, allergic reaction and nerve injury. Local injection BTX-A to treat RP secondary to SSc might be safe and effective. This article is protected by copyright. All rights reserved.

Raynaud's Phenomenon: Reviewing the Pathophysiology and Management Strategies

Raynaud's phenomenon (RP) is a multifactorial vasospastic disorder characterized by a transient, recurrent, and reversible constriction of peripheral blood vessels. RP is documented to affect up to 5% of the general population, but variation in its prevalence is commonly recognized owing to many factors, including varied definitions, gender, genetics, hormones, and region. Furthermore, RP may be idiopathic or be a clinical manifestation of an underlying illness. Patients with RP classically describe a triphasic discoloration of the affected area, beginning with pallor, followed by cyanosis, and finally ending with erythema. This change in color spares the thumb and is often associated with pain. Each attack may persist from several minutes to hours. Moreover, the transient cessation of blood flow in RP is postulated to be mediated by neural and vascular mechanisms. Both structural and functional alterations observed in the blood vessels contribute to the vascular abnormalities documented in RP. However, functional impairment serves as a primary contributor to the pathophysiology of primary Raynaud's. Substances like endothelin-1, angiotensin, and angiopoietin-2 play a significant role in the vessel-mediated pathophysiology of RP. The role of nitric oxide in the development of this phenomenon is still complex. Neural abnormalities resulting in RP are recognized as either being concerned with central mechanisms or peripheral mechanisms. CNS involvement in RP may be suggested by the fact that emotional distress and low temperature serve as major triggers for an attack, but recent observations have highlighted the importance of locally produced factors in this regard as well. Impaired vasodilation, increased vasoconstriction, and several intravascular abnormalities have been documented as potential contributors to the development of this disorder. RP has also been observed to occur as a side effect of various drugs. Recent advances in understanding the mechanism of RP have yielded better pharmacological therapies. However, general lifestyle modifications along with other nonpharmacological interventions remain first-line in the management of these patients. Calcium channel blockers, alpha-1 adrenoreceptor antagonists, angiotensin-converting enzyme inhibitors, nitric oxide, prostaglandin analogs, and phosphodiesterase inhibitors are some of the common classes of drugs that have been found to be therapeutically significant in the management of RP. Additionally, anxiety management, measures to avoid colder temperatures, and smoking cessation, along with other simple modifications, have proven to be effective non-drug strategies in patients experiencing milder symptoms.

Long-term results of ulnar and radial reconstruction with interpositional grafting using the deep inferior epigastric artery for chronic hand ischemia

Chronic hand ischemia causes cold intolerance, intractable pain, and digital ulceration. If ischemic symptoms persist despite pharmacologic treatments, surgical interventions should be considered. This retrospective study evaluated the long-term results after ulnar and radial reconstruction using an interpositional deep inferior epigastric artery (DIEA) graft combined with periarterial sympathectomy. Patients who underwent this surgery from March 2003 to February 2019 were included. To evaluate variables influencing recurrence after the procedure, patients were divided into the recurred and non-recurred groups and their data were compared. Overall, 62 cases involving 47 patients were analyzed (16 and 46 cases in the recurred and non-recurred groups, respectively). The median DIEA graft length was 8.5 cm. The rates of rheumatic disease and female patients were significantly higher in the recurred than in the non-recurred group, without significant between-group differences in postoperative complication rates. In the multivariate analysis, underlying rheumatic disease and graft length had significant effects on recurrence. In Kaplan-Meier analysis, the 5- and 10-year symptom-free rates were 81.3% and 68.0%, respectively, with lower rates for cases with rheumatic disease. Thus, arterial reconstruction using an interpositional DIEA graft provides long-term sustainable vascular supply in patients with chronic hand ischemia, especially in those without rheumatic disease.

Evaluation of Botulinum Toxin Type A and its Potential Effect on Exacerbated Raynaud's Phenomenon in Hospitalized Scleroderma Patients

BACKGROUND/AIMS

Raynaud's phenomenon by episodically reversible constriction of the arteries in the fingers and toes causes pain, numbness, sores, and gangrene. However, the treatment of Raynaud's phenomenon is one of the clinical issues. Recent studies have shown that botulinum toxin is considered a potential and effective therapeutic option for improving finger blood circulation in patients with Raynaud's syndrome. In this study, we sought to investigate the therapeutic effect of botulinum toxin type A on exacerbated Raynaud's phenomenon in patients with scleroderma.

METHODS

In this prospective study, 11 patients with systemic scleroderma who were referred due to aggravated Raynaud's were included. For all patients, questionnaires were filled up, and physical examination was performed separately for both treatment and control hands, and then similar volumes of botulinum toxin type A (Botox) and normal saline were randomly injected.

RESULTS

The results showed that there was a significant difference in Raynaud's score (P = 0.001), Quick-Dash score (P = 0.01), Mc-Cabe cold score (P = 0.003), the mean frequency of recurrences arracks (P = 0.01), pain (0.005) P = 0), skin color (P = 0.01), and duration of Raynaud's phenomenon (P = 0.006) between the intervention and control groups after two months.

CONCLUSION

Following Botox injection, a significant improvement in terms of various Raynaud's parameters as well as the clinical manifestations was observed in the intervention group. Together, botulinum toxin type A could retrieve the hand function, the cold sensitivity, and the painful feeling caused by Raynaud's syndrome.

Utilities of Botulinum Toxins in Dermatology and Cosmetology

Botulinum toxin (BoNT) is a neurotoxin produced by the Clostridium botulinum bacterium with a well-known efficacy and safety profile in the focal idiopathic hyperhidrosis treatment. BoNT comprises seven different neurotoxins; however, only toxins A and B are clinically employed. BoNT is lately practiced in off-label therapies for a variety of skin diseases. Scar prevention, hyperhidrosis, rhytides, eccrine nevus, alopecia, psoriasis, Darier disease, bullous skin disease, pompholyx and Raynaud's phenomenon are some of the novel indications for BoNT in cosmetic and notably non-cosmetic aspects of dermatology. To employ BoNT correctly in clinical practice, we must have a thorough understanding of the functional anatomy of the mimetic muscles. An intensive literature search was conducted to update all dermatology-oriented experiments and clinical trials on the described element of BoNT for this general overview of BoNT use in dermatology. This review aims to analyse the role of BoNT in dermatology and cosmetology.

Long-Term Sequelae of Frostbite-A Scoping Review

Frostbite is tissue damage caused by freezing temperatures and constitutes an important cause of morbidity in cold climate zones and high altitude. The direct effects of sub-zero temperatures lead to tissue freezing, electrolyte shifts and pH alterations, microvascular damage, and eventually to cell death. Upon rewarming, inflammatory reperfusion injury and thrombosis may lead to further tissue damage. Several studies and various case reports show that many patients suffer from long-term sequelae such as vasomotor disturbances (associated with susceptibility to refreezing), and neuropathic and nociceptive pain, as well as damage to skeletal structures. There are still many uncertainties regarding the pathophysiology of these sequelae. It has been shown that the transient receptor potential channel (TRP) family plays a role in cold allodynia. Botulinum Toxin type A (BTX-A) injections have been reported to be beneficial in vasomotor and neuropathic disturbances secondary to frostbite. Epidural sympathetic block has been used for short-term treatment of frostbite induced chronic pain. Furthermore, amitriptyline, gabapentinoids, and duloxetine may have some benefits. Frostbite arthritis clinically resembles regular osteoarthritis. In children there is a risk of epiphyseal cartilage damage leading to bone deformities. Despite some promising therapeutic concepts, the scarcity of data on frostbite long-term sequelae in the literature indicates the need of more in-depth studies of this pathology in all its aspects.

The Effects of Botulinum Toxin A on Pain in Ischemic Vasospasm

PURPOSE

The purpose was to describe the impact of botulinum toxin A (BTX-A) administration in patients with ischemic vasospasm on the magnitude and timing of pain relief and subsequent effect on opioid use. The secondary purposes were to determine the role of photoplethysomgraph (PPG) testing on treatment decisions, effect on patient-reported outcomes, and additional procedures.

METHODS

A retrospective analysis of patients who received BTX-A injections was performed. Botulinum toxin type A was injected subcutaneously in symptom-specific 2-level patterns. Pain, shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and opioid use (quantified by median morphine equivalents) were recorded and the need for repeat injections or unplanned surgeries was assessed.

RESULTS

All patients (n = 20 patients; 31 hands) had ischemic pain from vasospasm and failed multiple pharmacological options. Average follow-up was 10.5 months. All patients had abnormal PPG amplitude (mean, 6.43 mm) at room temperature and increased amplitude (mean, 19.55 mm) after immersion in warm water. All patients (n = 12) with a PPG amplitude increase of 4 mm or greater had clinical success. Eleven of 13 patients had a clinically relevant decrease in pain at 20 minutes after injection. Clinically significant pain relief was sustained for 3 months (visual analog scale decreased by a mean of 4). Median morphine equivalent usage view decreased from 82.5 to 0 after injection. Patient-reported disability (QuickDASH) improved from 49 before treatment to 29 and 26 at 6 weeks and 6 months after BTX-A injection, respectively. Three patients were retreated for recurrent symptoms. Four patients required unplanned secondary procedures.

CONCLUSIONS

Botulinum toxin type A administration can result in rapid (within 20 minutes) and sustained pain relief for several months with a reduction in opioid prescriptions. Botulinum toxin type A administration also improved patient-reported disability for 6 months. Use of PPG testing to determine baseline perfusion deficit and capacity to improve after warm water immersion was helpful in consideration of BTX-A use.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Botulinum toxin in the management of primary and secondary Raynaud's phenomenon

Raynaud's phenomenon (RP) is common in rheumatic diseases. In the setting of systemic sclerosis (SSc), it can be complicated by digital ischemia that includes ulceration and gangrene. Systemic adverse effects may preclude the use of oral or topical vasodilators for the treatment of RP and its complications. In this article, we review effectiveness/efficacy of botulinum toxin injection in primary and secondary RP. We discuss botulinum toxin formulations, dosage, sites of administration, and adverse effects. The evidence for botulinum toxin in the treatment of primary and SSc-associated RP is promising. Consistency across patient populations, treatment options (botulinum serotype, dose, and injection site), and outcome measures will be essential for further research.

Novel Combined Approach for Digital Necrosis Secondary to Raynaud's Phenomenon

The presence of severe Raynaud's Phenomenon (RP), with permanent pain or digital necrosis is a rare condition. Cervical sympathectomy or distal sympathectomy or A botulinum toxin have demonstrated efficacy after medical treatment failure. We report the case of a 38-year-old female patient with an acute onset of severe RP in both hands secondary to systemic sclerosis. Medical treatment failed, so a novel approach by a combination of a modified distal sympathectomy and injection of A botulinum toxin on digital neuromuscular bundles was performed. Remission of the pain occurred immediately after the procedure and 45 days later she had complete healing of the digital wounds and recovered full mobilization of both hands. The patient remained asymptomatic 6 month after the procedure, and a Doppler ultrasound showed tri-phasic flows distal to the surgical site. This novel technique is described, and a brief review of the literature is performed.

Botulinum Toxin A Treatment for Primary and Secondary Raynaud's Phenomenon in Teenagers

BACKGROUND

Raynaud's phenomenon (RP) is a clinical syndrome characterized by recurrent episodes of digital vasospasm triggered by exposure to physical and chemical agents or emotional stress. Although many pharmacologic treatments have been tested, there is still no cure or gold standard therapy. Botulinum toxin treatment has been proved to reduce pain and increase arterial blood flow in treated hands of adult patients with RP.

OBJECTIVE

The aim of this study is to evaluate the efficacy of botulinum toxin A on younger than 18-year-old patients with primary and secondary RP.

MATERIALS AND METHODS

A single-center prospective study was performed, including 8 patients aged 14 to 17 years who were clinically diagnosed with primary or secondary RP. BTX was injected into each hand without sedation or anesthetic blockade. The primary outcome was pain reduction after BTX injection. Pain intensity was evaluated at baseline and in the first follow-up. Secondary outcomes included variations in the number and severity of RP episodes after the BTX injection.

RESULTS

All patients stated significant pain reduction and decreased cold sensitivity, except one patient who did not feel any changes. No patients reported any loss of strength on thumb-index finger.

CONCLUSION

BTX injection is a simple, noninvasive, and cost-effective treatment alternative, offering an important nonsurgical therapeutic option for the pediatric population. It could also help optimize the dose of other treatments used in these patients. The most commonly observed positive effect is a reduction in the pain associated with RP attacks. Further studies are needed to confirm these results.

Therapeutic Use of Botulinum Neurotoxins in Dermatology: Systematic Review

Botulinum toxin is a superfamily of neurotoxins produced by the bacterium Clostridium Botulinum with well-established efficacy and safety profile in focal idiopathic hyperhidrosis. Recently, botulinum toxins have also been used in many other skin diseases, in off label regimen. The objective of this manuscript is to review and analyze the main therapeutic applications of botulinum toxins in skin diseases. A systematic review of the published data was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Botulinum toxins present several label and off-label indications of interest for dermatologists. The best-reported evidence concerns focal idiopathic hyperhidrosis, Raynaud phenomenon, suppurative hidradenitis, Hailey–Hailey disease, epidermolysis bullosa simplex Weber–Cockayne type, Darier’s disease, pachyonychia congenita, aquagenic keratoderma, alopecia, psoriasis, notalgia paresthetica, facial erythema and flushing, and oily skin. Further clinical trials are still needed to better understand the real efficacy and safety of these applications and to standardize injection and doses protocols for off label applications.

Digital Ulcers in Systemic Sclerosis

Digital ulcers (DU) are one of the most common complication of Systemic Sclerosis (SSc)-related vasculopathy and represent an important burden for the patients as well as for the society. Still today there is no agreement on the definition, classification and cathegorization of DU even if they are of pivotal importance in clinical practice, for treatment choice and prognostic outcomes, as well as for clinical trials. DU management requires a dedicated multidisciplinary team, that must remain ever vigilant for the development of infective complications and gangrene throughout their disease course, as well as patient education that is crucial to obtain the best compliance to assure the success of the treatment. Currently several drugs are available for DU treatment but in the future, more investigations will be needed to ameliorate the approach and the systemic and local therapies.

Botulinum Toxin for the Treatment of Intractable Raynaud Phenomenon

Raynaud phenomenon (RP) is a condition causing vasospasm in the fingers and toes of patients that can have a significant negative impact on quality of life. This can lead to pain, ulceration, and possible loss of digits. Several pharmacological options are available for treatment. However, RP can often be refractory to traditional modalities, leaving surgery or injections as the next available options. This article provides a review and update on the use of botulinum toxin as an effective therapy for the treatment of RP refractory to medical management.

A Prospective Pilot Study of Vascular Assessment of the Upper Extremity With Laser Angiography

Background: Our goal was to investigate patients' upper extremity tissue perfusion changes using an indocyanine green laser angiography imaging system for various pathologic states and interventions. Methods: This prospective observational study used Spy Elite/LUNA laser angiography to evaluate perfusion in patients with upper extremity vascular compromise. All patients had Spy Elite/LUNA imaging as well as clinical and handheld Doppler examinations preintervention, intraoperatively, if applicable, and at 1 week, 2 weeks, and 2 months postintervention. For each laser angiography scan, we used an unaffected control area with uninjured skin to quantitatively compare with the dysvascular tissues. Results: Twelve patients, 7 men and 5 women, had a total of 16 upper extremities evaluated. The mean age was 53 years, and half of the patients entering the study were smokers. Etiologies of vascular compromise were trauma, primary and secondary vasospastic disease, scleroderma, and intravascular drug injection. Interventions included surgical repair/reconstruction, botulinum toxin injections, and/or systemic medications. Improvement in perfusion following intervention was statistically significant, demonstrated by an increase in Spy Elite/LUNA quantitative score postintervention compared with preintervention scans. Adjusting for other variables, such as smoking and handheld Doppler signal status, demonstrated an independent statistically significant increase in Spy Elite/LUNA scores at all postintervention time points compared with preintervention scores. Laser angiography was able to confirm adequate vascular status, with ultimate tissue survival, in some cases when Doppler signals were not initially present. Conclusions: Laser angiography provided objective data to document improved upper extremity tissue perfusion following various interventions.

Botulinum toxin type A in the treatment of Raynaud's phenomenon

Raynaud's phenomenon is a vasospastic disorder clinically characterized by cold or stress-induced discoloration of the skin, pain and ulcers of the fingers or toes. Although this phenomenon might be self-limiting, there is a subgroup of patients requiring a therapeutic approach. The majority of patients do well on conservative measures; however, there is also a subgroup requiring systemic treatment. The efficacy of these systemic treatments is currently not thoroughly investigated. Furthermore, no uniform guidelines exist regarding the choice for a treatment option. In the past several years, several reports have shown the benefits of botulinum toxin for the treatment of Raynaud's phenomenon. In this case series, we report our experience with botulinum toxin type A in the treatment of Raynaud's phenomenon.

Scleroderma of the Hand: Evaluation and Treatment

Scleroderma is derived from Latin meaning hard skin. It is an uncommon, noninflammatory connective tissue disorder characterized by increased fibrosis of the skin and in certain variants, multiple other organ systems. Scleroderma involves a spectrum of pathologic changes and anatomic involvement. It can be divided into localized and systemic scleroderma. Hand involvement is common and can include calcium deposits within the soft tissues, digital ischemia, and joint contracture. Nonsurgical management consists of lifestyle modifications, biofeedback, therapy for digital stiffness/contracture, and various pharmacologic medications. When nonsurgical measures are unsuccessful, certain surgical options may be indicated, each with their inherent advantages and pitfalls. Patients with scleroderma who are undergoing surgical intervention pose unique difficulties because of their poorly vascularized tissue and deficient soft-tissue envelopes, thus increasing their susceptibility to wound healing complications and infection. Some subgroups of patients are frequently systemically ill, and specific perioperative measures should be considered to reduce their surgical risk. The spectrum of hand manifestations seen in patients with scleroderma will be reviewed with the focus on evaluation and management.

Targeted high concentration botulinum toxin A injections in patients with Raynaud's phenomenon: a retrospective single-centre experience

Raynaud's phenomenon is a vasospastic condition affecting hands and feet which may lead to rest pain, ischemic ulcers and gangrene. Botulinum toxin A has been shown to improve peripheral circulation and relieve vasospastic symptoms. Our aim was to assess our treatment outcomes following Botulinum toxin A injections in patients with Raynaud's phenomenon and to explore the importance of toxin concentration and injection sites. Retrospective chart review of patients with primary and secondary Raynaud's syndrome treated with Botulinum toxin A injections and a literature review was conducted. The toxin dose, injection sites, symptom relief, healing of ulcers and complications were assessed. A total of 30 treatment episodes over a 7½ year period were included. All patients had failed medical management. Botulinum toxin A injection was injected primarily in the vicinity of the palmar digital neurovascular bundle. The average total Botulinum toxin A dose injected was 156 U and the concentration was 50 U/ml. All patients reported an improvement in symptoms and healing of digital ulcers. One patient reported a temporary muscle weakness. Six patients had a single treatment episode with long term benefit. Systemic sclerosis patients had an average of 6-month interval between treatment episodes. Higher doses of Botulinum toxin A has been well tolerated with no long term adverse effects. Our study shows that targeted low volume higher concentration Botulinum toxin A injections are effective in treating Raynaud's phenomenon.

The Effect of Abobotulinum Toxin A on the Symptoms of Raynaud's Phenomenon: A Case Series

Raynaud's phenomenon (RP) is a relatively common syndrome occurring alone or in combination with autoimmune and inflammatory diseases. It is characterized by pain and ulceration due to vasospasm in response to cold and stress, most often affecting the digits. Although pharmacologic treatment for this condition exists, it is not always efficacious. Our case series demonstrates the use of abobotulinum toxin A in the treatment of RP. We report the cases of four patients who received injections of abobotulinum toxin A to treat their mild to severe RP symptoms. They experienced clinical improvement for up to one year after treatment.

Botulinum Toxin A Salvage of Ischemic Hand Trauma

Posttraumatic hand injuries from crush injury, infusion, or iatrogenic vascular cannulation can cause ischemic finger damage that can progress to necrosis and digital amputation. Botulinum toxin type A (Botox) improves blood flow in chronic vasospastic disorders of the hand. Botox's efficacy in salvaging ischemic loss in digits in acute traumatic and iatrogenic injury has not been previously reported. From February of 2015 to December of 2016, 11 patients at a Level I trauma center (West Virginia University) presented to the hand surgery service with early ischemic injury and vascular compromise to hand and fingers as a result of crush, direct drug injection, or proximal arterial injury from drug injection or catheterization. Before 2015, all patients with vascular compromise were treated with standard protocol. After January of 2016, patients were treated with additional injection of 80 to 100 U of Botox into the palm and wrist. Before administration of Botox, six patients with vascular compromise of one or more fingers were treated with a conservative protocol and 83 percent had amputation of necrotic digits. After January of 2016, five patients with ischemia were treated with Botox into the palm and proximal arteries. All Botox-treated digits were preserved (100 percent salvage). Pain scores were lower in Botox-treated fingers. We conclude that (1) in the acute traumatic vascular hand injury, early Botox injection markedly increases digital salvage; (2) direct nerve effects after Botox injections improve postinjury pain scores; and (3) early use of Botox in finger injuries is our standard approach to impending ischemia in the hand.

Ischemic Pain

This article discusses the pathophysiology, presentation, cause, and treatment of ischemic pain in the surgical patient. Causes of ischemic pain vary but all fundamentally cause local acidosis in the peripheral tissues, which causes signals to be passed through ascending pain pathways to the thalamus and eventual cerebral cortex where it is interpreted as ischemic pain. Ischemic pain is classically associated with an insidious onset but can present in the acute or chronic setting. Treatments are aimed at improving perfusion to the affected tissue. Surgical options include repairing damaged vessels, bypassing diseased vessels, performing thrombectomy, or embolectomy. Numerous conservative therapies exist.

Why Not Life and Limb? Vasopressor Use in Intensive Care Unit Patients the Cause of Acute Limb Ischemia

Background: Acute limb ischemia (ALI) of the upper extremity is a rare yet severe condition in intensive care unit (ICU) patients that generally leads to amputation. The aim of this study is to determine risk factors for development of upper extremity limb ischemia in ICU patients requiring vasopressor support. Methods: This is a retrospective study conducted from 2010 to 2015. Patients who received vasopressors during ICU admission were considered for the study. Patients were identified via Current Procedural Terminology (CPT) billing codes. ALI patients were matched to control patients based on diagnosis and Acute Physiology and Chronic Health Evaluation II score. Days on pressors, number of pressors, total doses, and level of ischemia were recorded. Primary end point was doses, types, and days on vasopressors. Secondary end point was level of ALI. Results: Patients in the ALI group were more likely to be started on a higher number of different types of pressors (2.6 vs 1.3 pressors). ALI patients received pressors for 8.5 days compared with 1.6 days in control patients, and received 12.8 doses compared with 3.0 doses in control patients. In addition, vasopressors with alpha-adrenergic activity were more likely to be used in the ALI group. Level of ischemia was not linked to any of the tested variables. Conclusion: Patients admitted to the ICU are more likely to sustain an acute ischemic event of an upper extremity with more vasopressor usage. Patients who received alpha-adrenergic activating vasopressors were more likely to sustain limb ischemia. When discoloration of an extremity is detected, patients should receive counteractive treatments in an effort to salvage the extremity and prevent function loss.

The effect of botulinum toxin type A in different dilution on the contraction of fibroblast-In vitro study

BACKGROUND

Botulinum toxin type A (BoNT-A) may directly remodel dermal tissues or induce a loss of normal morphology and cytoplasmic retraction and spread. Intradermal injection was claimed to produce a dermo-lifting effect, including midface lifting by using low concentration with variable dilution.

OBJECTIVE

To understand how intradermal BoNT-A achieves tissue lifting, we examined different type of BoNT-A and their effects on dermal fibroblast contraction.

METHODS

Normal human dermal fibroblasts were treated with onabotulinumtoxin (ONA), abobotulinumtoxin (ABO), prabotulinumtoxinA (PRABO), incobotulinumtoxinA (INCO), and letibotulinumtoxin A (LETI) in dilutions used in real-world practice. Fifty fibroblasts per dilution were photographed and measured the length to demonstrate their contraction every 2 hours from baseline (0 hours) to 12 hours post-treatment.

RESULTS

ONA did not significantly decrease fibroblast lengths, at any timepoint or dilution. At 1:7 dilution ratios, ABO decreased fibroblast lengths after 2 hours and significantly after 10-12 hours. At 1:7, 1:8, 1:9, and 1:10 dilution, PRABO decreased length, and most rapidly at 1:7 and 1:8. At 1:6, 1:8, 1:9, and 1:10 dilution, INCO decreased lengths almost immediately. At 1:6 dilution, INCO decreased lengths almost immediately. At 1:7 dilution, INCO decreased lengths after 2-4 hours, while at 1:8, 1:9, and 1:10 dilution, INCO decreased lenghts nearly imediately. LETI decreased lengths at all dilutions except 1:9, with near-immediate effects at 1:6, 1:7, 1:8, and 1:10. At 1:4 dilution, LETI decreased lengths from 1 hour.

CONCLUSIONS

Different commercial preparations of BoNT-A toxins cause different fibroblast contractions in vitro. Product selection and dilution used may affect the clinical outcome of intradermal injection of BoNT-A for face lifting.

Optimisation of botulinum toxin type a treatment for the management of Raynaud's phenomenon using a dorsal approach: a prospective case series

INTRODUCTION

Raynaud's phenomenon (RP) is a common condition and causes pain, paraesthesia, ulceration and gangrene. Botulinum toxin A (Btx-A) is effective when injected via a digital palmar approach, in the treatment of severe RP. However, hand weakness resulting from lumbrical malfunction is a recognized complication. This study aimed to determine the effect of Btx-A injected via a dorsal approach.

METHOD

Forty patients received 100 units of Btx-A, injected across both hands via a dorsal approach. Each patient had a baseline, 6- and 12-week hand assessment and thermographic image (FLIR E60bx) performed for the study.

RESULTS

Eighty-eight percent of patients reported an improvement in symptoms including reduction in pain, improved colour change with reduced swelling and edema at 6 weeks. Of these patients, 80% reported an improvement in cold intolerance with a reduction in the frequency and severity of Raynaud's attacks. There was a significant improvement in both the DASH score (p = 0.001), Kapandji score (p = 0.001) and hand strength (p < 0.05). No patients reported weakness. Improvements in hand function and symptoms of RP were still evident at 12 weeks.

CONCLUSIONS

Btx-A injected via a dorsal approach improves symptoms and reduces the number of RP. We have shown an effective non-surgical approach technique to treat RP.Key Points• Raynaud's phenomenon is a common vasospastic disorder of the digital vessels, which can cause severe pain, restrictions to hand function and ulceration.• Dorsal botulinum toxin type A injections can improve the symptoms of secondary Raynaud's phenomenon and hand function for approximately 3 months.

Surgical Treatment of Chronic Hand Ischemia: A Systematic Review and Case Series

Background: Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique.

Methods: A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations.

Results: The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation.

Conclusions: When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.

Role of botulinum neurotoxin-A in cerebral revascularization graft vasospasm prevention: current state of knowledge

Graft stenosis and occlusion remain formidable complications in cerebral revascularization procedures, which can lead to significant morbidity and mortality. Graft vasospasm can result in early postoperative graft stenosis and occlusion and is believed to be at least partially mediated through adrenergic pathways. Despite various published treatment protocols, there is no single effective spasmolytic agent. Multiple factors, including anatomical and physiological variability in revascularization conduits, patient age, and comorbidities, have been associated with graft vasospasm pathogenesis and response to spasmolytics. The ideal spasmolytic agent thus likely needs to target multiple pathways to exert a generalizable therapeutic effect. Botulinum toxin (BTX)-A is a powerful neurotoxin widely used in clinical practice for the treatment of a variety of spastic conditions. Although its commonly described paradigm of cholinergic neural transmission blockade has been widely accepted, evidence for other mechanisms of action including inhibition of adrenergic transmission have been described in animal studies. Recently, the first pilot study demonstrating clinical use of BTX-A for cerebral revascularization graft spasm prevention has been reported. In this review, the mechanistic basis and potential future clinical role of BTX-A in graft vasospasm prevention is discussed.

Relaxation matters: comparison of in-vitro vasodilatory role of botulinum toxin-A and papaverine in human radial artery grafts

Background

Radial artery (RA) is widely used in coronary artery bypass (CABG) surgery and the prevention of spasm is crucial for graft patency. Botulinum toxin A (BTX-A) and B are commonly used for aesthetic reasons and neuromuscular disorders. They are proven to raise blood flow and increase survival of ischemic skin flaps. In this study we evaluated and compared the vasodilator effects of BTX-A and papaverine on human RA grafts.

Methods

After resting 60 min in isolated organ baths, human RA grafts were examined. Contraction responses for different doses of serotonin (5-HT) and endothelin-1 (ET-1) were evaluated as a percent of maximum contraction response elicited by 80 mM potassium chloride (KCl). The inhibitory effects of BTX-A and papaverine on contraction responses taken at the 0th hour were compared with the 1st and 2nd hour responses. Inhibitory effects of BTX-A and papaverine against the contractile agent were evaluated by comparing the results of the first and last (0th and 2nd hour) application.

Results

In low concentrations, when we compared the effects of BTX-A (10^− 8 M) and papaverine (10^− 6 M) on 5-HT, papaverine was found to be more effective at both the 0th and 2nd hour (p < 0.05). Both BTX-A and papaverine inhibited the maximum contractile effect of ET-1 to the same extent at the 0th hour; but, the inhibitory effect of BTX-A was significantly stronger at the 2nd hour (p < 0.05).

In high concentrations, when we compared the effects of BTX-A (10^− 6 M) and papaverine (10^− 4 M) on 5-HT, papaverine showed stronger inhibition (p < 0.05), whereas both agents had similar action of inhibition on ET-1 mediated maximum contraction responses.

Conclusion

BTX-A inhibits both ET-1 and 5-HT induced contractions and its effectiveness does not decrease over time as observed with papaverine. This study is the first in the literature using human RA for prevention of vasospasm by BTX-A.

Botulinum toxin type A in the treatment of Raynaud's phenomenon: A three-year follow-up study

Objective

Raynaud’s phenomenon consists of vasospastic disease of the digital arteries after exposure to cold or stress. It causes an important reduction in the patient’s quality of life when severe. The available treatments do not always offer favorable results.

Methods

A 3-year retrospective study was presented. A total of 15 patients with severe Raynaud’s phenomenon who required infiltration with botulinum toxin type A participated in the study. In the first and follow-up visits (30 min, 7 days, 3 months, 6 months, and annual), the overall response by the patient was assessed as was the reduction in the number of weekly episodes of Raynaud’s phenomenon, improvement in pain by means of the Visual Analogue Scale, and resolution of ulcers and necrosis as efficacy variables.

Results

A total of 15 patients were included in the study. After 30 min of infiltration, the immediate results showed a very good perception of response in four patients. After 1 month of treatment, eight patients had obtained and maintained a very good response, persisting throughout the study. A statistically significant reduction in pain was obtained, as well as the number of weekly episodes of Raynaud’s phenomenon. Of the seven patients with basal ulcers, five were completely healed at 3 months. Of the patients, 64.3% showed an overall satisfaction level of >8 at the end of treatment. No serious adverse events were observed.

Conclusion

Botulinum toxin is a useful treatment for severe Raynaud’s phenomenon that is generally well tolerated. Its mechanism of action is not based exclusively on vasodilation. Further studies are necessary to define the ideal patient for this treatment, the most appropriate method of administration, and the number of units and frequency of the infiltrations.

Botulinum Toxin Injection for Lower Face and Oral Cavity Raynaud Phenomenon After Mandibulectomy, Free Fibula Reconstruction, and Radiation Therapy

Isolated lingual and lower face Raynaud phenomenon without primary Raynaud of the digits is a very rare condition associated with chemoradiation therapy (RT) in previous reports. The condition, which more commonly presents in patients with a history of Raynaud disease, is often self-limiting, but vasodilating agents and steroids have been suggested as possible treatment options. Spasmodic torticollis is a different, more common entity, also associated with history of RT or previous head and neck surgery. We present a rare case of a patient who developed Raynaud phenomenon of the lower face and tongue in the presence of spasmodic torticollis after mandibulectomy and free fibula reconstruction followed by RT to the oral cavity and neck. Possible causes, pathophysiologic mechanisms and treatment options are discussed. This is the first report of botulinum toxin treatment of isolated secondary Raynaud phenomenon of the lower face and tongue.

Botulinum toxin B suppresses the pressure ulcer formation in cutaneous ischemia-reperfusion injury mouse model: Possible regulation of oxidative and endoplasmic reticulum stress

BACKGROUND

We previously identified that botulinum toxin A (BTX-A) suppressed pressure ulcer (PU) formation after cutaneous ischemia-reperfusion (I/R) injury; however, regulation of cutaneous I/R-induced oxidative and endoplasmic reticulum (ER) stress by BTX-B was not investigated. Additionally, the efficacy of BTX-B injection has never been examined.

OBJECTIVE

Objective was to assess the effects of BTX-B on the formation of PU by cutaneous I/R injury, and the regulation of oxidative and ER stress in I/R injury by BTX-B.

METHODS

BTX-B was subcutaneously injected into I/R area, and wound size, vascular damage, hypoxic area, and apoptotic cells in I/R area were analyzed. We evaluated the extent of oxidative and ER stress in I/R area by using OKD48 mice and ERAI mice, respectively, which enabled evaluating oxidative and ER stress through bioluminescence detection.

RESULTS

BTX-B injection significantly suppressed the formation of PU by cutaneous I/R injury. Cutaneous I/R-induced vascular damage, hypoxic area, and number of oxidative-damaged cells and apoptotic cells were suppressed by BTX-B injection. BTX-B administration significantly inhibited I/R-induced oxidative stress signal in OKD48 mice. BTX-B reduced the I/R-induced oxidative stress-associated factors. BTX-B significantly inhibited the oxidant-induced reactive oxygen species and apoptosis of endothelial cells and fibroblasts. BTX-B significantly inhibited I/R-induced ER stress signal in ERAI mice. Cutaneous I/R injury-induced ER stress-response factors and GRP78/BiP and CHOP-positive cells in I/R area were significantly decreased by BTX-B injection.

CONCLUSION

BTX-B injection might have protective effects against PU formation after cutaneous I/R injury by reducing vascular damage, hypoxia-induced oxidative and ER stress, and apoptosis.

The mechanism of botulinum A on Raynaud syndrome

Background

Botulinum neurotoxin type A (BoNT/A) is emerging as a treatment modality for Raynaud's phenomenon (RP). However, the mechanism of the role of BoNT/A in antagonizing the constriction of arteriola in RP remains unclear.

Materials and methods

We tested the constriction of arteriole diameter and the distribution of adrenergic receptors on the rat cremaster modle. Moreover, we measured the secretion of norepinephrine (NE), protein level changes and related receptors on cultured rat superior cervical ganglia neurons(SCGNs), a model of sympathetic neuron.

Results

Based on our results, the inhibition of arteriole vasoconstriction was increased with increasing doses of BoNT/A. BoNT/A, prazosin, and BQ123 treatment can result in significant inhibition of arteriole vasoconstriction with the same electrical stimulation. The inhibition effect of prazosin was equivalent to BoNT/A, while BQ123 has a synergistic effect with BoNT/A. After treating SCGNs using BoNT/A for 30 min, the decrease in fluorescence intensity of FM1-43 slowed down which was correlated with the doses of BoNT/A. Furthermore, release of NE in the supernatant was significantly decreased as measured by enzyme-linked immunosorbent assay, 24 h after a high dose of BoNT/A (25 µ/mL). Cleaved-SNAP-25 was detected by Western blotting 24 h following BoNT/A (50 µ/mL) treatment. Moreover, receptor SV2C, GM1, and FGFR3 were detected on sympathetic neurons, similarly to cholinergic neurons.

Conclusion

Our study showed that BoNT/A could significantly inhibit electrical stimulation-induced arteriole vasoconstriction through the sympathetic pathway. The mechanism was similar to the cholinergic one, in which the vesicle release of sympathetic neurons could be inhibited by cleavage of SNAP-25. The end result was blocked vesicle fusion with the presynaptic membrane after BoNT/A treatment, inhibiting the release of the NE.

The non-neuronal and nonmuscular effects of botulinum toxin: an opportunity for a deadly molecule to treat disease in the skin and beyond

There is growing evidence that botulinum neurotoxins (BoNTs) exhibit biological effects on various human cell types with a host of associated clinical implications. This review aims to provide an update on the non-neuronal and nonmuscular effects of botulinum toxin. We critically analysed recent reports on the structure and function of cellular signalling systems subserving biological effects of BoNTs. The BoNT receptors and intracellular targets are not unique for neurotransmission. They have been found in both neuronal and non-neuronal cells, but there are differences in how BoNT binds to, and acts on, neuronal vs. non-neuronal cells. The non-neuronal cells that express one or more BoNT/A-binding proteins, and/or cleavage target synaptosomal-associated protein 25, include: epidermal keratinocytes; mesenchymal stem cells from subcutaneous adipose; nasal mucosal cells; urothelial cells; intestinal, prostate and alveolar epithelial cells; breast cell lines; neutrophils; and macrophages. Serotype BoNT/A can also elicit specific biological effects in dermal fibroblasts, sebocytes and vascular endothelial cells. Nontraditional applications of BoNT have been reported for the treatment of the following dermatological conditions: hyperhidrosis, Hailey-Hailey disease, Darier disease, inversed psoriasis, aquagenic palmoplantar keratoderma, pachyonychia congenita, multiple eccrine hydrocystomas, eccrine angiomatous hamartoma, eccrine sweat gland naevi, congenital eccrine naevus, Raynaud phenomenon and cutaneous leiomyomas. Experimental studies have demonstrated the ability of BoNT/A to protect skin flaps, facilitate wound healing, decrease thickness of hypertrophic scars, produce an anti-ageing effect, improve a mouse model of psoriasiform dermatitis, and have also revealed extracutaneous effects of BoNT arising from its anti-inflammatory and anticancer properties. BoNTs have a much wider range of applications than originally understood, and the individual cellular responses to the cholinergic impacts of BoNTs could provide fertile ground for future studies.

The Role of Botulinum Toxin A in the Treatment of Raynaud Phenomenon

Raynaud phenomenon (RP) is a transient digital ischemia that occurs after exposure to cold temperature or emotional distress. It presents with a triphasic course: the initial white phase is followed by cyanotic discoloration and, subsequently, erythema. The attacks may be associated with pain, paresthesia, and complicate with nonhealing ulceration often leading to amputation. To date, there are no clear-cut therapeutic guidelines and many medications are used off-label. Encouraging results were reported with the use of botulinum neurotoxin-A (BoNT-A). However, there is still ongoing debate regarding indications, contraindications, best injection technique, and mechanism of action. The aim of this study was to address these issues by providing an up-to-date and detailed overview of the use of BoNT-A in RP.A PubMed database search was conducted. The available studies and techniques were evaluated and compared.The search yielded a total of 29 studies. Ten papers, published between 2004 and 2014, were considered relevant. A total of 128 patients underwent BoNT-A injections. Seventy-five percent to 100 % of the patients reported pain reduction after treatment. Healing of ulcers was reported in 75% to 100% of the affected patients. The most common complication was temporary hand weakness, with an average incidence of 14.1%. Injections targeting the neurovascular bundle at or slightly proximal to the A1 pulley were the most commonly performed.Botulinum neurotoxin-A injection proved to be a valid approach in both primary and secondary RP. The available evidence shows the achievement of both symptomatic and functional improvements in this debilitating condition. However, the patient should be adequately informed about the risk of transient hand weakness.

The Therapeutic Efficacy of Botulinum Toxin in Treating Scleroderma-Associated Raynaud's Phenomenon: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial

OBJECTIVE

To assess the therapeutic efficacy of local injections of botulinum toxin type A (Btx-A) in improving blood flow to the hands of patients with Raynaud's phenomenon (RP) secondary to scleroderma.

METHODS

In this randomized, double-blind, placebo-controlled clinical trial, patients with scleroderma-associated RP received Btx-A (50 units in 2.5 ml sterile saline) in one randomly selected hand and sterile saline (2.5 ml) in the opposite hand. Follow-up at 1 and 4 months postinjection included laser Doppler imaging of hands, patient-reported outcomes, and physical examination. We compared outcomes using paired t-tests and population-average generalized models with generalized estimating equations.

RESULTS

Of 40 patients enrolled, 25 had limited scleroderma and 15 had diffuse scleroderma. From baseline to 1-month follow-up, there was a greater reduction in average blood flow in Btx-A-treated hands compared to placebo-treated hands. The model estimated that this difference was statistically significant (average difference -30.08 flux units [95% confidence interval -56.19, -3.98], P for interaction = 0.024). This difference was mainly influenced by patients with longstanding RP and diffuse scleroderma. Change in blood flow at 4-month follow-up was not significantly different between groups. Clinical measures (QuickDASH, McCabe Cold Sensitivity Score, pain on a visual analog scale, and Raynaud's Condition Score) improved slightly for Btx-A-treated hands.

CONCLUSION

Our laboratory-based laser Doppler imaging flow data do not support using Btx-A to treat RP in all scleroderma patients. The secondary clinical outcomes suggest some positive effect, but its clinical meaningfulness is questionable. The role of Btx-A in treating RP should be further studied with more homogeneous patient populations and in unique clinical situations such as acute digital ischemia.

Botulinum Toxin Off-Label Use in Dermatology: A Review

BACKGROUND

Botulinum toxin is a neurotoxin produced by the bacterium Clostridium botulinum which causes a flaccid muscle paralysis. It is currently used for aesthetic treatments and in the focal hyperhidrosis. Recently, botulinum toxin has also been used experimentally in many other dermatological conditions with good results.

OBJECTIVE

To review and analyze the possible botulinum toxin off-label applications published.

METHODS

A retrospective review of the published data was conducted.

CONCLUSIONS

this potent drug can lead to several off-label indications of interest for dermatologists. Further clinical trials are still needed to better understand the real efficacy and safety of these applications and to standardize injection and dose protocols.