Microbotox for facial redness

Rosacea is a chronic, usually recalcitrant and recurrent skin condition with a significant aesthetic aspect. Thus, it affects self-confidence and quality of life. Several topical and systemic treatment modalities are available to treat different forms of rosacea. Intense pulsed light (IPL) or vascular laser treatment could be suitable for treating facial erythema and telangiectasia. However, none of these methods seem effective in treating flushing episodes. In this context, botulinum toxin (BTX) microdroplet therapy emerged as an effective method to treat erythema, flushing, and subjective complaints associated with rosacea.1, 2 In this issue of the Journal, Takahashi et al. applied incobotulinum toxin intradermal injections to treat different subtypes of rosacea. They reported a significant positive impact on clinical signs and symptoms of the disease. The treatment improved participants' quality of life and self-esteem scores for most patients with minimal side effects.3 BTX has gained broad popularity and is used for treating a wide range of diseases. The mechanism of action beyond preventing neuromuscular activity could be the decrease of sweat gland activity, sebum production, or the inhibition of vasodilation. The latter reaction develops as a result of the toxin's effect on the cholinergic nerve endings of the sympathetic nervous system combined with the impact that the modulation of neuropeptides such as VIP and CGRP produces; these peptides play a role in the underlying neurovascular mechanisms behind rosacea. Similarly, BTX is presumed to have a mast cell membrane stabilizing effect resulting in the alleviation of the flushing and burning sensation.4 "Mesobotox" or "microbotox" treatment entails the superficial intradermal application of usually hyperdiluted (compared to standard dilution) BTX using microboluses (Figure 1). The microdroplets are placed at equal distances from each other, with usually one injection placed at every 1 cm in a grid-like pattern. This technique can be used on the entire face, neck, and décolleté surface without the risk of unwanted muscle relaxation, assuming the correct dosage and proper technique. The recommended dosage depends on the type of BTX and the indication or treated surface. The microdroplet technique represents an off-label technique. The most popular and most widely used toxins are abobotulinum toxin (ABO-BoNTA), onabotulinum toxin (ONA-BoNTA), and incobotulinum toxin (INCO-BoNTA). The application of BTX microinjections appears to be a promising option for treating different subtypes of rosacea. If botulinum toxin treatment is combined with energy-based treatments, the toxin treatment is suggested to be the last step to avoid any side effects caused by the physical manipulation of the tissues. Flushing is the most frustrating sign of rosacea, which is relatively resistant to standard treatment modalities. Therefore, microbotox treatment could be a real breakthrough, considering how it improves patients' quality of life. Vincent et al. recently investigated the efficacy of BTX for the treatment of flushing.5 Two randomized controlled trials and seven nonrandomized studies were enrolled in this analysis, evaluating flushing outcomes, mainly the clinical flushing score, the dermatology life quality index, and the erythema index. All parameters showed improvement one month after the BTX treatment.5 More clinical trials are needed, specifically to determine the ideal dose and dilution of the applied BTX product, as well as the duration of its effect.