Botulinum Toxin Mesotherapy for Refractory Rosacea

acne rosacea of female face
acne rosacea of female face
Management of rosacea can be challenging in light of the persistence of vascular symptoms that may occur following topical and systemic treatments.

Diluted botulinum toxin (BTX) injection for the treatment of refractory vascular and papulopustular rosacea, repeated every 4 to 5 months, has shown promise for relieving persistent vascular symptoms, according to a recent analysis conducted in India and published in the Journal of the American Academy of Dermatology.1

Under local anesthesia, BTX diluted to a strength of 10 units/mL was administered intradermally in the hypervascular and telangiectatic centrofacial face as microdroplet injections of 0.05 mL with 0.5-cm spacing. Significant reductions in edema, erythema, telangiectasis, and flushing were observed within 1 to 2 weeks of treatment. Any remaining papulopustular lesions also demonstrated improvement, and a reduction in pore size was apparent at 2 weeks.

With the improvement observed lasting for approximately 3 to 4 months, repeat sessions of BTX mesotherapy are needed once every 4 to 5 months in order to maintain remission. The use of dermoscopy in such patients permits a more objective assessment of their therapeutic response.

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The therapeutic benefits of BTX observed in patients with rosacea most likely stem from acetylcholine blocking effects targeting arrector pili muscles and local muscarinic receptors in the sebaceous glands.2 The improvements observed in BTX-treated patients with respect to erythema, flushing, and inflammation occur as a result of potent blockade of acetylcholine release from autonomic peripheral nerves of the cutaneous vasodilatory system, along with inhibition of the release of such inflammatory mediators as calcitonin gene-related peptide and substance P.3,4

The authors noted that although use of diluted BTX mesotherapy every 4 to 5 months is associated with the relief of vascular signs and symptoms of recalcitrant rosacea, the procedure is limited by the cost and the need for repeated injections.


1. Bharti J, Sonthalia S, Jakhar D. Mesotherapy with botulinum toxin for the treatment of refractory vascular and papulopustular rosacea [published online May 19, 2018]. J Am Acad Dermatol. pii: S0190-9622(18)30808-9. doi: 10.1016/j.jaad.2018.05.014.

2. Campanati A, Martina E, Giuliodori K, Consales V, Bobyr I, Offidani A. Botulinum toxin off-label use in dermatology: a review. Skin Appendage Disord. 2017;3(1):39-56.

3. Dayan SH, Pritzker RN, Arkins JP. A new treatment regimen for rosacea: onabotulinumtoxinA. J Drugs Dermatol. 2012;11(12):e76-e79.

4. Bloom BS, Payongayong L, Mourin A, Goldberg DJ. Impact of intradermal abobotulinumtoxinA on facial erythema of rosacea. Dermatol Surg. 2015;4(suppl 1):S9-S16.