04 January, 2013

BOTOX for facial flushing and rosacea


Yeah you are reading it correctly; botox. Not meant to straighten out faces, but injected superficially in the skin's surface, this procedure shows promise for some of the nastier cases of vascular rosacea. Botox for rosacea is not the same as botox for wrinkles. It is not injected into the muscle but is given subcutaneous. I haven't done this procedure myself (yet) but two dear friends from overseas, one my age and one a little bit older and both with severe facial flushing and recalcitrant rosacea, have had this procedure done under the care of very good and specialized dermatologists. One of them is a leading European dermatologist, the other Dr. Michael Masters from the US.

Note; I only gather personal experience, info from the net and from forums and use it for this blog. I don't do advertisement or making any money in whatever shape or form off of this blog. 

I am quoting and paraphrasing some information from both doctors about this topic:
Flushing in rosacea (or possibly flushing in general) is at least partially mediated by acetylcholine. There may be some reason to think that those with more severe flushing may have enhanced reaction to it. So what do we have that would selectively block acetylcholine? Botox. It works by blocking the acetylcholine receptors on muscles. There are also acetylcholine receptors on blood vessels. The muscles are much deeper than the skin. If severe flushers are more sensitive to acetylcholine, it would make sense that blocking acetylcholine receptors on superficial blood vessels might be very helpful.  The doctor wondered if acetylcholine receptors on superficial blood vessels could become hypersensitive and lead to even more flushing possibly while there might be concurrent "improvement" in the blood vessels with laser. (Source).

When the doctor was at the American Society of Derm Surgery week before last in Atlanta, he talked to one lady that he respected a great deal about using Botox for flushing because of its acetylcholine blocking effects. She has tried it (with success) and by the following procedure. She got Botox, which comes in a vial with 100 units (in powder form) which would be reconstituted with sterile saline to be able to inject.  Everybody may use different amounts but usually it's usually around 1 to 3 cc of saline (the doctor uses 2 cc). She dilutes with 7 cc. and she uses a very small 3 or 4 mm long needle (a so called mesotherapy needle) to place the Botox very superficially in small amounts.  A half inch needle is 13 mm. A few years ago, another dermatologist from somewhere like Laos or Cambodia gave a presentation in one of the small lunch lectures at the American Academy of Dermatology in which instead of using longer needles, she used a short needle to inject the Botox much more superficially all over the face for rejuvenation. Our lady in question used a grid of 1 centimeter areas on the involved cheek (Botox can diffuse up to 1 cm in the skin) and no more than 10 small injections (one per each centimeter section on the grid) per session.  She says she has had some success, some very good success in more severe flushers but she has just started doing this.

A possible down side from the botox procedure for facial flushing would be that you have to use the Botox superficially in areas that you wouldn't want to relax muscles (ie if using Botox like we usually do on foreheads deeper).  So you would want to go slow--maybe try just a couple injections a centimeter apart to see if you were a responder before doing the 10 injections per treatment. Of course there is the theoretical consideration that it would take more than a couple of injections to see improvement because you might need to treat a larger network of vessels to really affect the flushing response. The doctor doesn't think rebound would be a consideration.  If it helps, you would see the flushing coming back as soon as the Botox wears off, but that isn't really a worsening or rebound.
One of the unknowns is always how long the effect will last, if it helps. For cosmetic muscle relaxation, the first time a patient is treated with Botox the average therapeutic effect is 18 weeks. It is however unknown how long it will last when used for facial flushing.  Botox is also used for hyperhidrosis (extensive sweating) of the hands and axilla (blocking acetylcholine receptors again) and may last somewhat longer then.


The doctor treating my friend thought that there is enough science to warrant a trial with superficial Botox, also since some other people have already tried it with success.

After the first treatment session with the superficially applied botox, my friend wrote to her doctor that she had not experienced any discernible paralysis of any kind yet. They botoxed the main flushing area, but did not travel up her nose OR up her right temple. Normally she would have late afternoon and evening flushing for many hours, starting under the eyes and working it's way down the entire cheek area. After the botox, she mentions that in the afternoon she had clear beginnings of a flush but only around the edges; on the nose coming down to the botoxed area and then stopping where the botox was injected. The non botoxed area was on fire yet the botoxed area was okay, although not great yet. But she saw and felt a clear difference. Her severe night flushings were cut down from 6 to 4 hours now. Both realized that more treatment of a bigger facial area are needed but in the ongoing days my friend continued to see a reduction in facial redness and flushing in the treated area. She wrote in relation to this: "Apparently a tiny initial flush transmits some signal to the adjacent blood vessels that they should dilate, too. That's the message we need to shut down."

Her doctor responded to this that he was cautiously optimistic with his good news, especially about the fact that there is now a discernible difference between the botoxed areas and the areas that weren't botoxed. He noted that he used the absolute minimum dose that he thought would have any affect this first time and found the lack of muscle relaxation also very encouraging. He wrote: "It will also be interesting to see if there is any "decay" in the botox area as far as effectiveness or if it will hold until you get to your appointment in a few weeks.  Even if it loses some of its "power", that is not necessarily bad news because the dosage was so low."

In two weeks time they planned to do another treatment. The doctor will use a slightly higher dosage this time and treat a bigger facial area.

After this second treatment my friend wrote to her doctor that she was delighted to announce that she had gone six days without the horrible nightly flushes, something totally new to her. She also flushed less to her usual triggers (high temperatures to name one). She would normally flush daily. She found that she can still trigger a flush when she exposes herself to temperatures over 65 degrees but she realized as well that they are still in the process of treatment. Her doctor was also enthusiastic, but warned against jumping all over it, doubling the dose and perhaps overreact. "My inclination would be to repeat the same dosage in the same areas we did last time and this time be sure to get the areas that were "less bad" nearby and see the response and how long this helps.  I have no heartburn about doing higher dosages if we have to.  It also sounds like you wouldn't mind even if you get some muscle relaxation, but maybe if we proceed slowly and titrate the dosage based on the affect and longevity, you wouldn't have to get muscle relaxation.  Also, the Botox treatment so far has had minimal recovery time for you so if you did "break through" we could get you in and treat you fairly quickly without horrible recovery time."



(Source) "Before (A) and after (B) injectable botulinum toxin (Botox®, 10 U, 0.05 mL aliquots every 1–2 cm) intradermally into each cheek in combination with pulsed dye laser (10 mm, 10 msec, 7 J/cm). Note: Clinical results and symptomatic relief were seen rapidly after the treatments.




Her latest update (17-1-2013)


"Hi doc,

Well, it's been three weeks now since my last purpuric V Beam and I wanted to update you.
Frankly,  I'm quite impressed with the Botox! The burning and flushing since the last injection (60 units) is much less, so my suffering is way down.  The flushes come less often;  they don't last as long,  they are clearly less intense,  and they ALSO don't hurt as much. That last part is amazing.  I'm used to feeling anxious when the flushing starts because the pain is so intense and all-encompassing.  Have you seen Botox cut down on pain with other patients, too? I'm impressed, amazed, and grateful. I've gone almost a week now without the usual painful, nightly, massive, full-right-face flush.  That's amazing because usually my flushing is pretty horrific after a V Beam. It must put a LOT of heat into the face. This is the biggest improvement I've seen in ten years of dealing with this disability, which (until now) has worsened every year. The flushing is not completely gone by any means,  but it's much more controllable. I will still flush painfully if I'm exposed to heat or if I eat the wrong foods (sugar, grain, or tyramine),  but the flushes now last about an hour or two instead of 6, 7, or 8 hours.  It's not pleasant but it's no longer god-awful. Being able to live in my (63 degree) condo with less suffering and pain is a major improvement. Thank you for your thinky thoughts on this and for pursuing that Cambodian woman at the conference who told you about the tiny needles. The right side of my smile is still paralyzed and I don't care.  I see the beginnings of freedom from this disability and it's wonderful."


I couldn't find any information in the literature on how long the Botox lasts on vascular acetylcholine receptors. When it is used for muscle relaxation, the literature says that the average time it lasts the first time is 18 weeks. Subsequent treatments last longer. Some of that may be related to muscle atrophy (sort of like how a muscle will atrophy when not used if kept in a cast for 6 to 8 weeks) but the doctor didn't think that was the whole story, as patients who are treated with botox for migraine tend to have lasting effect for up to 8 or 9 months. Migraines are vascular, but we treat the muscle relaxation also because a large number of migraines also seem to be triggered by muscle contraction headaches that botox blocks. (some sort of recruitment or cascade phenomenon?)  But maybe there is a component of blocking vascular acetylcholine receptors as well.
In the upcoming months my friend will have more botox treatments to find the right dose and duration time and look for more improvement on her flushing. In the mean time she reported to me a significant reduction in her flushing. Instead of daily severe evening and night flushing she has now virtually none, or short lived ones. She did start to feel some numbing and paralysis, that is related to botox in general at the moment but nothing bothersome and she seems mainly bewildered and overjoyed with the much needed break in her severe and very painful flushing.




The other friend had several botox treatments under supervision of  her dermatologist (but done by another specialist) in 2008 and 2009.
She has a very reactive and aggressive case of vascular rosacea, where she would literally spend at least half of the year in the house with a fan on, windows open and cold packs at hand, despite already taking anti flushing medication (which was already taking off a good % of her initial flushing). Despite being on several anti flushing medications she still suffered and at some point her specialist thought it was time for some drastic action and he arranged a colleague and specialist from his hospital to start doing the botox treatments on her in a bid to calm matters down.
She had 40 injections in her cheeks and mentioned that it hurt, perhaps due to the numbing cream not having enough time to work, as she had an emergency treatment due to her despair. The treatment took about 20 minutes for her. She wrote that she returned home bright red and with some tiny needle spots over her cheeks. "There was no side effects from the botox. It only hurt when it was being done."
After 5 days there was no change and she felt deflated.  But on the 6 or 7th day, which was Christmas eve, she didn't feel too bad and wrote that  she had the fan on low all day but no icepacks or chillow pillow and she even got groceries in without any skin drama. In the evening she managed to go over to friends and managed without cold packs or a fan."Christmas day we went to my mums I was not red, I was not majorly hot, I sat at the table with everyone for dinner for the first time in 3 years! I was able to enjoy the day, play with my nieces, I felt a Christmas miracle had happened."The day after she had a good time with other friends and reported a 90% improvement to what it used to be.
"When the doctor suggested botox I thought to myself i have tried for 3 years so many tablets to no real avail and although I wanted it to work I couldn't fathom how after 3 years some injections in my face that I could possibility be loads better in just 7 days.  But I am. [..] When I go back in 4 weeks time to see the botox doctor I am going to ask to have my chin and forehead done as although they don't really go red, the burning is still there.  Also my ears (but I don't think you can have botox on them). I am wanting to go everywhere, cinema, meal out, to see a band...Its unreal."
 
She later updated on day 12 since the treatment that she was still doing a lot better, but that she had to use her fan on low now and again. She wasn't flushing or red or burning but just felt more comfortable with the fan on low. Her cheeks could still turn slightly pink but nothing like it used to be.
Her botox doc later replied to her by email that she would it would need to continue to improve and that she could have a top up if needed; a bit extra in the worst areas because they were always conservative to avoid side effects.

She didn't experience side effects, as the doctor was very careful not to go too deep, in case  she would react. "But they do warn you that in a very small percentage of people i.e 1% you can get temporary paralysis, this takes about a month to wear off.  But my best friend gets botox all the time and she has never had a problem.  I have been told it  lasts between 4 - 6 months."
In the weeks that followed she mentioned a continued improvement, although no complete elimination and she still needed to use a fan on low often. But she could go out, meet people again and have more control over her facial flushing and burning now. 


Unfortunately after the next botox treatment the improvement wasn't great. She had by then approximately 100 injections in her cheeks but was still flushing unless she had the fan on a constant low. She also still flushed at night during sleep. It seemed the initial good response wore off slightly. The botox doctor didn't want to give her even more injections and she and her doctor looked into other medication options at this point. Note that she was a very severe flusher.

Her medication at the time was

Labetalol 100mg x 1
Mepacrine 150mg
Maxalt 20mg per day (like sumatriptan)
Clonidine 25mg 3 tabs, 3 times a day
Ucerax 25mg, 3 times a day (antihis)
Arcoxia 60mg, one a day.

Still these medications weren't controlling the symptoms enough.

Her botox time table (for rosacea):
Botox: 17th Dec 2008
Botox: 14th Jan 2009
Botox: 20th May 2009
Botox: 27th November 2009 x 40
Botox Friday 11th Dec 2009 x 28 (top up)
Botox : Friday 16th April 2010 approx. 12 in each
Botox: Friday 6th August 2010 approx. 12 in each
Botox: Friday 28th Jan 2011



She updated me yesterday:


"I had quite a few botox treatments bout every 3/4 months. 20 injections in each cheek. I found it very painful but i would go throught anything if there was a chance it could help. Basically i had periods of flushing and not flushing (which is how i am all the time) so i have never known whether the botox was helping or not helping, sometimes id be good after it for a few weeks, other times it would be worse for a few weeks. To be honest I don’t no if it had any effects as years later I still had good time and bad without the botox, I don’t even no whether the tablets do anything, as I’m up and down even while on them, hence why i have stopped a lot of them as no point taking them if they aren’t really doing nothing. i had flare up after each botox for a good week, then mostly settled down for a bit. The last few times was worse after the treatment so i decided to stop it as was painful and not sure if was doing anything. i remember it did help for a while at the beginning as i put a thing on the rosacea site saying i was so much better, but this could all be a coincidence. For me i really believe that it cant be controlled well. If it wants to be bad it is and if it wants to be good it is. I don’t cut out foods or anything. I just enjoy when I’m not flushed and bear with each day when it aint. for me the overriding element ids the weather 100%. That’s why I’ve prob been great this xmas, as last 9 years been freezing and snowing, and now we haven’t even got the heating on?!"




 

Online there is also information to be found on rosacea and botox. The following page is dedicated to the topic:

 Dr Nich Soldo MD mentioned about it:
"Botox is only an adjunct to many ways to address flushing. Most commonly used are IPL, clonidine in low doses, oracea and topicals such as metrogel etc to name a few. Botox does not reach peak effect for at least 2 weeks and sometimes even longer. If not effective by then, then a larger dose may need to be used. Botox is not foolproof however and is not always totally effective."

Andrew Reid said about it that as “someone who has had botox injections experimentally to try and treat rosacea and rosacea flushing, this is a step forwards. I had a frozen face for 2-3 months and effect on flushing was difficult to gauge. There have been very mixed reports on botox for facial flushing and redness, based on my personal experiences I would not recommend this to others (for the face).”

Bob Bear mentioned: "the results were pretty startling. It didn’t help my rosacea flushing at all, but my blushing was gone in the treated areas. No word of a lie! Since then, it seems that several people from the ESFB group have achieved similar results with this treatment.”
Ann said: “I too have HAD injections of botox after numerous treatments of IPL. I have found it to be very helpful with the flushing component of rosacea as well as eliminating the symptoms of the heat related facial areas. In conjuction with IPL, I have found botox to have been very helpful in managing my condition.”
Glamormon had botox treatments with Dr Soldo and stated: “We did Botox this week injected into the skin (dermis I think) . A little punch feeling and the needle was in, no big deal (but thenI was slathered in topical). Tiny little pin point bruises in a couple spots, can’t see them at all under makeup. We used 20 units all over the flush zone including on the ears. Even the top of nose got 2 units. I’m pretty exicted about the possibilities this offers, and feel really lucky to have such easy access to Dr. Soldo.” (Forum post)


laser_cat wrote on The Rosacea Forum on July 24th 2017: "Hi Nat!
Yes, my botox is being done specifically for rosacea. Not totally sure if there is technique specific for rosacea or not but I think perhaps there is. I've had 5 treatments so far I believe. I didn't see any results until maybe 4 weeks after the 5th treatment. The last 2 injections, my derm consulted with a derm in NYC who has had success using botox for rosacea.

Treatments are $$ but I am very fortunate that insurance covers mine. Without insurance they would be ~1000$ / tx I believe. My last 2 injection rounds were 100-110 units each, a lot of little injections covering full face and ears. The NYC doctor told me that patients should generally see ~60% improvement 3-5 weeks after injections, but sometimes a few treatments are needed to get the ball rolling. The NYC doctor also said most people don't know that very high doses work best and are afraid of them. One injection round should last 3 months, so they say.

My post here 

I had been diagnosed as "severe, uncontrolled neurogenic rosacea" and believe botox has made a decent dent into it. The biggest improvement being I can lie down at night. Hoping I will see more results over time.

Best,
Lizzy"



Here a more scientific disquisition is given on the specifics on botox in rosacea treatment:
"Acetylcholine is a major neurotransmitter that is released by certain types of nerves (sympathetic, parasympathetic, and sensory nerves). After being released from nerve endings, acetylcholine can bind to sweat glands (resulting in sweat formation), and blood vessels (resulting in dilation). Lately, there has been extensive research into the role of acetylcholine in nerve-mediated disorders, especially those that are accompanied by skin flushing and sweating.
BOTOX® treatment is extremely effective at blocking the release of acetylcholine from nerve endings in the facial skin (BOTOX® is a vaccine derived from botulism bacteria; Botulinum Type A, Allergan). BOTOX® treatment consists of superficial injections into the affected area of skin. The safety and effectiveness of BOTOX® in the treatment of neural-mediated disorders of the facial skin has been extensively studied (review of the current medical literature on Medline indicates that several dozen peer-reviewed clinical studies have been performed on hundreds of patients). These studies indicate that BOTOX® can safely be injected into the nose, cheeks, chin, forehead, temples, and certain portions of the eye area and eyelids. Currently, this vaccine is being used to treat facial muscle spasms, wrinkles, frown lines, eye twitching, nostril flaring, and crossed eyes. Additionally, BOTOX® has been used extensively to treat neural flushing and sweating disorders of the face (i.e., Frey Syndrome). Some of these studies have been highlighted in a
medical review article in the Archives of Neurology (1999), “Botulinum Toxin in the Treatment of Neurological Disorders of the Autonomic Nervous System”.  There is recent clinical evidence indicating that skin flushing to internal body heating can be completely abolished by cutaneous BOTOX® treatment. Dr. Dean Kellogg and colleagues demonstrated that BOTOX® treatment of normal human skin completely blocked active skin flushing that is caused by increases in internal body temperature. Interestingly, this study also suggests that BOTOX® may block other dilator neurotransmitter substances that may be co-released with acetylcholine."

There are some anecdotal reports mentioned from physicians and patients indicating that botox treatments can for some reduce certain forms of facial flushing. Also: "In the treatment of superficial neural disorders, the vaccine’s effectiveness may wear off in 5 to 9 months. Additionally, the cost of BOTOX® may limit the use of this therapy (it is quite expensive)."



Here a case is mentioned where botox eliminated facial flushing in a rosacea patient:
"Botox has been used as a novel method for the treatment of persistent facial flushing in rosacea sufferers. We report a case of persistent facial flushing that was resistant to multiple pulsed dye laser treatments and was successfully treated with botulinum toxin A. Results: The post treatment appearance was dramatic, and the patient was highly satisfied with the cosmetic outcome.”[2]

[2] Botulinum Toxin for the Treatment of Facial Flushing Melanie Yuraitis, MS, and Carolyn I. Jacob, M 
Dermatologic Surgery, Volume 30, Number 1, January 2004, pp. 102-104(3)

This is a pubmed article on Botulinum Toxin for the treatment of Rosacea.  




And on The Rosacea Forum the topic is also discussed several times. 

Ivory wrote: "I had really really bad facial flushing (I'm part-Welsh as well, so I think it might have been pre-rosacea, though I never developed bumps) which involved every trigger imaginable from hot drinks to cold weather, but the worst was definitely emotions (i.e. even slight unease!). Anyway, I tried 6 sessions of IPL, and had lots of comments about how nice my skin was, because it went quite porcelain-like ... but then I tried some beetroot soup which tasted really disgusting so I must have had an emotional response that made me turn red because someone laughed at how I was 'redder than the soup' (like I said, my triggers were everything imaginable!) so I knew IPL hadn't stopped the flushing, only the background redness. So I booked a session of botox, as there have been suggestions that this works for some people. Turns out that I was one of the lucky ones (apparently it works well for about 1 in 3 people and okay for another 1 in 3) because it worked absolutely perfectly - I didn't flush for 11 months afterwards (including when I was doing really intense exercise). Then I went back to get another load as I was worried that it would wear off (apparently, for wrinkles, it almost never lasts for more than a year) - though I could have left it longer. It usually only works for 4 months though, so that's something to bear in mind. The only real problem (aside from the cost) is that if you get the injections too near your mouth it sometimes means you can't smile properly for a month (which is a much much bigger problem than it sounds!!!) so be careful initially to have it quite away from the mouth to see how it affects you (my second treatment didn't have much of an effect on my smile because it wasn’t done so close to my mouth). I hope this helps people who feel they are running out of options - it's certainly worth a shot if flushing is affecting your life."
-Arlene replied to this: "I would love to try botox for the flushing that I have left but,with the exception of Dr. Soldo, there doesn't seem to be anyone in the U.S. willing to do it. There have been other threads on this topic (I think all from people in the uk and Australia) that seem to indicate that the results do vary from nothing to total cessation of flushing. I brought it up with my own doctor at my last treatment and he felt that there is not enough medical evidence regarding efficacy. Oh well". 
-Snoop replied: "I had a few sessions with a botox clinic and it didnt work, maybe lightened my face a little but nothing for flushing." (Link to forum post)



Arlene later had botox done herself as well and wrote: "Had a consult with Dr. Jafri yesterday regarding botox for my existing areas of flushing. Pleasant enough guy, has a certain criteria for whether or not he'll attempt to try it. Feels not worth time or money if Rosacea too severe, skin too thickened by disease and laser etc. Also related information that I knew- results varied widely etc. We then went into the examining room to look at my face under the lights and magnifier. He thought that my Rosacea was "moderate" and that I might benefit from the botox (along with continued laser treatment) and agreed to start by trying a small area 2 weeks after my next laser tx on 12/27. Figure it's worth a try. Will update after I do it on 1/7"
-Antwantsclear replied to this: "it does sound like he knows what he's talking about. As I said on the other thread about this, I think botox is most useful in early stage cases of rosacea where there is little damage to the skin in terms of swelling or significant thread veins on the surface, because it has no anti-inflammatory effect to reduce the size of those surface veins or heal that skin. All it can do is to reduce blood flow under the skin (and this is somewhat limited compared to the more effective anti-flushing medications). But it's good that he recognises its limitations because it suggests that he's treated several rosacea patients with botox" We are waiting for Arlenes update on the upcoming procedure. (Link to forum post)


Snuffleupagus also wrote about botox for rosacea:
"So i saw my derm today and he said he was at a conference in Cleveland for botox. He talked to the woman and they concluded it would be possible to use it to help for flushing/pain, although she hasnt done it. He said it has been used for lupus and other conditions. He has another really good specialist here and I am being referred to him. Says we'll see what he says, but it's worth a try at least on one side of my face. What do you guys think? Also argh, needles im so afraid of them! haha. Hopefully it would be okay (no bruising/swelling stiff cheeks) and also i hope it doesnt affect my pustules/papules - especially since i think they put some topical on you beforehand?! Anyone know also if you can do this in conjunction with PDL (vbeam, yag, etc.) Seeing as the botox wont help redness if it is combined with PDL (obviously with time between) perhaps it could address all the symptoms - flushing, redness, pain. Thanks guys!"

-RedFaced replied: "I have read several reports, some say it did nothing, others say it really helped and in some cases even resolved the flushing/pain. It is hit and miss from what I have read so let us know how it goes and good luck to you."

-Meg reported on her negative experience: "I suffer from severe and painful flushing. A little over a year ago, my pain management doctor tried the full face botox on me, after he had heard of and researched some of the success stories. I have to say it was extremely painful - nothing like having your forehead done. And sadly, after going through getting over 100 shots in my face, it really did nothing to help. With that said, I have heard stories of it helping flushing, but I'm not aware of anyone personally who has benefited. And yes, I did have topical numbing cream as well as pain meds, but it still hurt like nothing I have ever experienced. Also, because of the regular flushing, my face bled a lot during the procedure, resulting in some short term bruising."

-Arlene has a hilarious rant then writing "There are soooooooo many jerks with machines out there. They are worse than used car salesmen ( sorry to the used car salesmen). Try to sell you procedures and products. Hate it when you know more about the disease than they do. This one set a tech on me while she pumped my friend with botox and tried to sell her on a lifestyle lift. Bragged to her that she doesn't look 60- looks every bit of it. Stuck at the moment because of my leg. Plaquenil helping and trying to maintain so will do 2 more and get the hell out. Then will rat her out to Dept of health because illegal to use tech in NJ. Hopes she likes her license". Moral of the story could be; be careful what jerk (doc) with a machine you go for :)

-Steve95301 had a botox treatment for his rosacea and reported: "I am t+48 hours and I already see a pretty big difference. In fact I was noticing a difference even yesterday. Both yesterday and today, after taking a hot shower I have not been flushed at all. My baseline seems to be improved 10-30%. Every time I think (feel) that I'm flushed, I'll take a look and I'm not. But I haven't put it to the real test yet, which will be those stressful afternoon meetings that I dislike so much. I'll report back next week on how that works out (I'm taking vacation this week.) I'm quite pleased so far. All the signs are promising. The nurse who was cleaning my face off after the procedure told me she had a friend who used Botox for flushing and loved it, she said it helped her by 60%." Three and a half days later he updated: "The results are better than I had hoped (well, they are approaching my best-case scenario). My baseline is still improved 15-30% and I have not flushed once since the treatment. I have tested it by doing flush-inducing things: hot showers, hot thermostat, food (hot dogs) but my face remains calm/unflushed. Like every rosacean I am suspicious of things that seem too good to be true, but it sure is hard to argue with the results I'm seeing in the mirror. Now my only concern is whether or not I can do this the rest of my life ;) I emailed the Dr. to ask if there is any reason to believe I would become resistant to Botox with continued use." 
He then updates: "It is possible to flush through the Botox. It's not perfect, but it knocks the flushing down about 70%. [..] Effects seem to have strengthened. Starting last night I noticed I can only make 1/2 to 3/4 smile, so some Botox apparently has lodged in the muscle tissue. I've had some nausea today, which is a Botox side-effect, but may be unrelated." Followed by: "My face is frozen to a large degree now. It's strange how the Botox kicked in very rapidly between yesterday and today. I can smile with the middle of my mouth but the edges cannot go upward, so my smile looks a bit like a sneer - I will need to practice in the mirror.
However, the anti-flushing effects are also stronger. Today I was on 6 hours sleep and had several meetings, but was quite pale through the day. I can "feel" the Botox again in my skin, like a numbness - I find it reassuring. Days 1 through 4, the anti-flushing effects were strong (I would not rule out a placebo effect, or the influence of my taking vacation and having low stress, or effects from the Botox vehicle solution, etc.), but they seemed to wane a bit after that. Then all of a sudden, yesterday, I noticed that I can't smile and my face is pale (or, more accurately: "
He then developed some photo sensitivity from the botox (presumed) but he praised it's effect and was slightly disappointed when the effects started to fade after 3 months, but loved what it did for his flushing and rosacea. (Link to the forum post

Aprblush had botox treatments recently and reported improvement of her flushing and moderate facial redness. She keeps a blog post here.




Pictures by Albert Arthur Allen, ca 1922
As usual this isn't a break through treatment solution for vascular rosacea, but just one weapon in the battle.

It might not work for everybody and I personally am a bit fearful of the time the botox stays in your system. Some might find 4 to 6 months a short period, and this might be true when it is beneficial for your case, but if the opposite is going on and say you have a bad reaction to it, then 4 to 6 months is a very long time to sit out. Another down side is the cost and the fact that you would have 2 or 3 treatments a year theoretically, although that might perhaps be brought back to one. Like with IPL treatments, I am not sure it is fully understood yet what long term use of this substance can mean for overall health. A lot of people are doing ok with IPL for their flushing, but might develop problems in the long run, from using the device too many times. A lot of question marks still therefore, but when you are suffering on a daily basis from bad flushing and burning, I would certainly give this procedure a try. Under the hands of a specialist, not in a SPA.



21 November 2013
On the Rosacea Forum someone brought up this article on special anaesthetic injections which are injected into the neck to reduce hot flushes with 50% (or so they claim). I have no idea how safe this procedure is and only post it for information value. Here this procedure is discussed on the rosacea forum. 



14 October 2013
This is an article about Anesthetic injections having the potential to ease hot flashes. 





Anaesthetic injection could ease hot flushes

Injecting a local anaesthetic into the neck is associated with a 50% reduction in hot flushes among women with moderate to severe symptoms.

A shot in the neck may curb extreme hot flushes associated with menopause, a small new study suggests.
Injecting a local anaesthetic into an area of the neck that communicates with the brain's temperature regulation zone was associated with a 50% reduction in hot flushes among women with moderate to severe symptoms, the researchers reported.
Since research over the last decade has suggested that taking hormone replacement therapy to control menopausal symptoms may be associated with increased risk for heart disease and cancer, many women have been searching for a safe and effective non-hormonal means of reducing hot flushes.
The anesthetic treatment isn't designed for everyone with hot flushes. It's intended for those struggling with truly troubling hot flushes that occur regularly, affecting quality of life, said study author Dr David Walega, chief of the division of pain medicine at Northwestern University Feinberg School of Medicine in Chicago.
"This is for people with multiple drenching sweats, women who can't function in the workplace, who have extreme anxiety preceding the hot flash. And when that happens several times a day, we also see anxiety and depression," explained Walega. Some breast cancer patients stop taking their medication – tamoxifen – because it causes hot flushes, he added.

What are hot flushes?
Hot flushes are sudden feelings of heat or warmth starting in the face and extending to the neck and chest area, sometimes accompanied by sweating and flushing of the skin. They are associated with menopause, but can also occur in patients taking oestrogen-blocking medications, typically for breast or prostate cancer. Walega estimated that hot flushes affect more than 80% of menopausal women.
To deliver the treatment, the physician uses guided imaging to inject a local anaesthetic into what is called the stellate ganglion, an area between the thyroid gland (around the "voice box") and the carotid artery. "The patient feels a sense of intense pressure from the physician's finger [guiding the needle], and the pain is moderate," said Walega. "In 30 seconds, we're done."
The researchers got the idea of attacking extreme hot flushes by treating the stellate ganglion from unintended consequences of a pain study published in The Lancet in 2007. "Patients reported their pain was still there, but their hot flushes were gone," Walaga said. 

Anaesthetic injection
For this study, scheduled for presentation at the American Society of Anaesthesiologists' annual meeting in San Francisco, the researchers recruited 40 women between 35 and 65 years old. All were either in natural or surgically (when the ovaries are removed) induced menopause.
Half of the women received a stellate ganglion blockade injection of bupivacaine hydrochloride, a local anaesthetic. The others were given a placebo, an injection of sterile saline. Participants kept track of their hot flushes for two weeks preceding the injection and six months afterward.
The researchers found that stellate ganglion blockade reduces the incidence of hot flushes by half, especially in women with moderate or severe hot flushes, and the benefits appear to last for at least six months. Subjects also reported experiencing less depression after getting the bupivacaine injections, and they demonstrated improved verbal recall of spoken words.
Walega said the treatment is safe when done by specially trained physicians using X-ray fluoroscopy to guide the injection. The stellate ganglion sits near the carotid artery, the vertebral artery and the spinal cord. "Injecting any of those arteries with anaesthetic could cause a seizure and loss of consciousness, and it could do damage to the spinal cord," he explained. As for the risk of radiation exposure from the fluoroscopy, it is equivalent to that of a chest X-ray, he added.

Resetting the thermostat
Why might these injections work? Walega said he thinks the ganglion may play a role in turning certain nerves on or off. "It's complex and there's so much else we don't know," Walega said. "We might be resetting the thermostat." Walega now plans to do a larger study with more than 200 participants, he noted.
Dr Grace Forde, an attending physician and pain management specialist at Syosset Hospital in New York, noted that a large percentage of the patients receiving the placebo also reported an improvement in their hot flushes. "Invasive procedures often have a much stronger placebo effect," she noted.
Walega estimated that the treatment, if proven effective in a larger study, would cost between $750 and $1000.
Forde, who was not associated with the study, said she thinks the benefits of the treatment probably outweigh the risks. "You can't put a price on quality of life. I personally think it's worth it."
Because this study was presented at a medical meeting, the data and conclusions should be viewed as preliminary until published in a peer-reviewed journal.



Interesting, I asked my derm about this treatment option and this is what he replied:
´The anesthetic will effectively act as a temporary sympathectomy. I have one patient who had a surgical sympathectomy but only have mild and short lived improvement of the flushing.´
I'm nevertheless curious how this treatment option will develop though.    




March 28th 2014
Ablusher wrote about his/her botox trial for facial flushing and redness on February 1st 2013
"Hi guys so i had Botox done today for facial blushing/flushing.
I'm going to make this thread a diary log! Firstly my type of blushing: My skin normally looks pretty normal just a very slight red tint ..then when i blush it burns and turns extremely red! The injections - They were slightly painful nothing to bad, just a bit eye watery! Straight after - I had red dots kind of like i had been bitten all over my cheeks (where the injection points were). This settled down pretty much 30mins-1hour after. 2hours later - My face is pretty clear now although if you look closely you can see the injection points i can imagen this will disapear in 24hours! I've been told i will notice results (if it works) in 2-4weeks so i will keep you all posted! If anyone has had botox done and it worked for you please let me know the good signs i should be looking out for "

"Day 2: Alot of the redness has gone, i look pretty normal just one small red patch that looks small enough to be a spot..im guessing it will disapear by tommo as it has cleared up a lot since yesterday!
This is just a quick log as i've got to go out! ile put in some more detail later but so far thumbs up as i went out last night and had no feeling or fear of blushing even in awkward moments for some reason my skin felt strong (sounds weird i know and might be a plceabo effect). Will update when i got some spare time!"

"Good news today, got out the shower......no red face! i even had a steam before and a hot shower to test it out! This could be good news for us all! The red patch that looked like a spot had now gone, cant see the injection points anymore ..pretty clean face right now "
"Yeah i flush in warm rooms sometimes. Yeah i flush when i drink alcohol and i was told to keep protected from the sun but i never did really ha i love the sun!

Update: i had a no xplode in the gym today (drink with very high cafine content) then i come back and had a hot steam and a shower.. currently having a very minor blush! nothing to worry about as its only very slightly red i'd say its roughly 20-30% of my usual blush id get! and the burning sensation didn't happen! I was told it takes up to 2-3weeks for the botox to work sometimes.. so it still may get better? but i only had a small dose anyway i think it was 30-35units per side! so roughly 70units in total maybe next time i go for 50units each side! In my opinion: So far id give this treatment 7-8/10 pretty happy.. Will keep logging."

"Quick update: Like i said before i only had 35units of botox each side but i still feel confident that this is helping, i had a slight blush today after my shower.. but no burning sensation which makes the blushing worse and i feel because this sensation didnt happen it cleared up a lot quicker!
In my opinion so far i would say i need to up the units of botox next time to see a even better improvement but i feel comfortable to say i think it might be working! still no side effects
I feel a lot more calm about my cheeks since i had the botox for some reason. I will update you all again soon, if my replys start to slack its only because of how rushed my life is right now with work! But if i have a major blush you guys will be the first to know!  Trial and error people "



Arlene (Arb161) also kept a diary about her experiences with botox for facial flushing and redness
-Feb 4th 2013 "Thought I would move my botox updates here so information would be all in one thread. Hope it's ok. Two weeks post second treatment. My symptoms are intense flushing for 10 years, mostly to heat. Unless it's 65 degrees I flush. Have had every kind of laser treatment. Now using vbeam perfecta which has improved my condition but still have spots of severe flushing. Taking a conservative approach with botox , increasing amount in solution with each treatment, and not treating entire face. Last treatment had 3 times the amount of botox as the first. Right now doing cheek area on both side of nose which have been very resistanot to laser. Also forehead above eyebrows. So far I have found that the botox has improved permanent redness but flushing, maybe just a little. Forehead had stopped flushing for a few days but it came back. I don't have permanent redness there and it usually responds to laser but did not respond to my last treatment 1/28. Next botox treatment next monday.
Arlene"

Feb 9th 2013 "Just thought I would update my expeerience with second botox treatment 3 weeks ago. Not too much to report. Some improvement in redness in treated areas of cheeks. Minor improvement in flushing. No improvement on forehead which does not have permanent redness but does flush. Will report after next treatment (hopefully will be dug out from snow) scheduled for Monday
Arlene"

Feb 13th 2013 "Had my third treatment Monday. The doctor has agreed to write out all the details regarding units, percentage botox etc. in an email, which hopefully I'll get soon. Most of the permanent redness in the cheek (there for years) area is gone. It used to flush the moment I woke up but it does not do that any longer. i haven't been in a warm room yet and I doubt that it will hold up to an extended period of heat. Forehead (does not have permanent redness) still flushed this morning. So annoying! Forehead was clear for over a year and last vbeam did not stop flushing either. Next appointment in 4 weeks.
Arlene"

Feb 15th 2013 "I want to be clear that i am doing vbeam as well as the botox. I know that I've said this before, but I really feel that a lot of times it's the doctor and not the laser that is the problem. I have a really severe case. In the beginning vbeam put me in remission. But it became ineffective and I was told that I was laser resistant. I went back to vbeam with another doctor (this time perfecta) after trying everything else. By the time I went back, the disease was in over drive and had spread to my neck and chest. I also had scars from botched treatments. Although it has greatly improved my quality of life it has not put me in remission. I think I will probably need both, but I would be happy never to see a laser again. So far, the botox has done more to improve permant redness than it has for flushing. I'm glad about that but It's the flushing that makes my life miserable. Went into a bank that felt like walking into an oven yesterday. I flushed pretty quickly but did notice some white areas in the botox treated part of my face. Hope that continues. Have not heard from the doctor regarding details as yet. Arlene"

Feb 17th 2013 "Botox has definitely decreased the flushing in parts of my cheek. I'm sure now about this as I flushed after blood work and went into the bathroom next to the room to look in a mirror. White areas in the treated areas. Same amount was put in forehead, however it flushed- weird.
Arlene"

March 12th 2013 "Got fourth treatment yesterday. Doctor said he sent me email about concentrations but I must have thought it was spam and deleted it. Said he would send again. My third treatment was very effective at reducing the redness in the treated areas about 90 percent. Got some back along the way. I think I got a little effect on the flushing but only that it takes a bit longer to start when I am in a heated area. We are still not treating all the places where I flush (have patches along the side of face which eventually take over. Also have areas on neck and chest ) until I get to a point where I get the most effect with the lowest concentration of botox. Again, as the concentration of botox to saline increases I require less injections. Next treatment in 6 weeks.  Arlene"


In another thread Arlene continued updating:
May 16th 2013 "So at 2 weeks I thought nothing was happening. I was still flushing and red from my last v beam treatment 7 weeks ago as well. The next day I woke up and there was a large improvement in the redness and flushing. Of course the test is when I go into a heated store (someone please tell me why they have to be 80 degrees) Still flushed but threshold was longer especially left cheek. Arlene"


In another thread Arlene also updated:
February 2nd 2014: "Unfortunately not good news- Had a major flush in response to minor stress. Just an annoying conversation about a medical bill. Felt it coming on from untreated areas and before I got off the phone it had spread to the treated areas. It seems to me that so far, in terms of flushing, more improvement to heat related triggers than to stress. Also has improved on permanent redness."


Arlene stopped reporting at this point, but replied last month in another thread on her botox experience:
February 1st 2014: "Results seem to vary greatly from nothing to 100% success. I tried it last year and had a number of sessions with the strength of the botox increasing. It did not work at all for me, but it was worth a try"


Snoop tried botox and didn't have success with it:
-He/she wrote on February 11th 2014: "Don't bother. I had about 6 treatments with a doctor for botox and it failed to work. I also fainted during one procedure."




April 29th 2014

Mat83 mentions that he still uses botox and finds it effective for his rosacea: "Also part of my routine is getting 25 units of Botox (diluted) injected intradermally into my forehead and cheeks (in the top layers of skin and not as deep as for wrinkles) every 4 months, 3 times a year. The Botox has helped tremendously more then the vbeam ever helped me in terms of reducing flushing, blushing, p&p's, and really has no downtime. Botox even helps with acne and oily skin, its done wonders for my rosacea."

7 comments:

  1. Is it possible to make a list of doctors that provide this at the moment? My derm is so old school I wouldn't even know where to start. Thanks for everything.
    PIppa

    ReplyDelete
  2. I haven't had botox treatments myself yet.... I know Prof. Tony Chu from Hammermsith hospital (dermatologist) has had a colleague treat some of his rosacea patients with botox. I can have a look at the forums for more info/names, but I have no way of checking how reliable, safe and experienced they are so I am a bit hesitant.. Will have a look though. Best wishes

    ReplyDelete
  3. Thanks-I wouldn't even know where to look in the US. I guess I'd be more inclined to try this than IPL since I have vascular rosacea with burning and the botox would wear off after a time.
    On an unrelated note-I did a search and didn't find any hits on this but have you heard anyone using lidocaine on the burning? It's supposed to deaden the nerves for a bit. Pippa

    ReplyDelete
  4. Hi Pippa,

    someone actually asked about Lidocaine on The Rosacea Forum very recently: http://www.rosaceagroup.org/The_Rosacea_Forum/showthread.php?23891-Whats-all-this-phantom-burning-about-eh-Neurogenic-Rosacea-AKA-Burning-but-no-flush/page4
    I posted there a link to a very good article on rosacea by a prof. and she also mentions Lidocaine as a possible treatment option, although there have not been many on the forum who have tried this, or at least reported on it. Someone is about to try it though she wrote. http://www.medscape.org/viewarticle/776148_transcript
    With regards to botox, there is a member called Arb161 there who saw a specialist for her botox treatmenst for rosacea in New York. And Mat83 also mentioned he had succes with botox here: http://www.rosaceagroup.org/The_Rosacea_Forum/showthread.php?30604-Mirvaso-recovery

    ReplyDelete
  5. Thanks for the info and links, Nat. I finally posted on the forum. I am wondering about using sumatriptan on my face. I take it for migraines and it is a nasal spray so it is in liquid form. I am wondering about spraying it on my face. I posted the question on the forum too. I guess I could to a test patch and see. Thanks again for keeping your blog updating. I love all your pictures too.

    Pippa

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  6. Thanks for the compliment Pippa, its nice to read some feedback :) I will have a look on the forum for your post and the replies you get on it. I honestly wouldn't know if spraying sumatriptan on your face would be beneficial... I asked for it to be taken orally but my GP refused, despite dr Chu suggesting it. She says it has way too many serious potential side effects and patients using it need very strict screening. Not sure if she tried to scare me but she also mentioned risk of heart attacks and what not. It is supposed to constrict the blood vessels in the face, leading to the brain. That;s how it should help with migraine, but I didn't push it with my GP as she seriously made me worried about this drug. I'll ask Dr Chu about it when I see him again later this year. But maybe spraying it on your face would also help and give less serious side effects. However, so far all the topical vasoconstrictors (like Mirvaso and brimonidine) have had big issues with the rebound vasodilation that automatically follows such an unnatural constriction. The body and brain over compensates, to correct the situation. I wouldn't be surprised if this would also happen with sumariptan, but I don't know of anyone who has ever tried it yet, so who knows. Just be careful with this drug though, in general I mean. Best wishes Nat

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  7. I highly recommend botox, great stuff.

    ReplyDelete

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