Med Lasers 2023; 12(4): 263-266  https://doi.org/10.25289/ML.23.041
Menopausal facial erythema and flushing successfully treated with broadband light and botulinum toxin: a case report
Jiwon Lee1, Sang Ju Lee2, Han Kyoung Cho1
1Department of Dermatology, Myongji Hospital, Goyang, Republic of Korea
2Yonsei Star Skin & Laser Clinic, Seoul, Republic of Korea
Correspondence to: Han Kyoung Cho
E-mail: trpchk@hanmail.net
ORCID: https://orcid.org/0000-0001-6074-013X
Received: November 17, 2023; Accepted: December 4, 2023; Published online: December 12, 2023.
© Korean Society for Laser Medicine and Surgery. All rights reserved.

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
In menopausal patients, transient facial flushing may lead to persistent erythema and telangiectasias, causing psychological distress and a poor quality of life. Hormonal therapy is the primary treatment for menopausal symptoms, but its use remains limited due to the increased risk of cardiovascular and thromboembolic events. Nonhormonal therapies focus on lifestyle modifications, and energy-based devices have not been sufficiently evaluated. This case report describes the treatment given to a 52-year-old female presenting with menopausal facial erythema and flushing who received a combination of broadband light and intradermal botulinum toxin injections. This case highlights the need for further research that compares various energy-based modalities and their efficacy with established pharmacological treatments for menopausal flushing.
Keywords: Botulinum toxins; Erythema; Flushing; Intense pulsed light therapy; Menopause
INTRODUCTION

Menopausal symptoms affect up to 80% of menopausal women and can adversely affect their quality of life [1,2]. Hot flashes, a common menopausal symptom, last several minutes, and begins as a fleeting sensation of heat accompanied by flushing, sweating, and chills that extend across the upper body [2]. Hot flashes last for an average of 7.4 years, but its duration may vary depending on race or ethnic group [1]. Chronic repetitive and strong facial flushing may cause a loss of vascular tone, resulting in a permanent background of redness and telangiectasias, creating psychological distress [3]. Nonpharmacologic therapies for menopausal symptoms are generally less studied. Specifically, studies on energy-based devices for the treatment of menopausal flushing and erythema remain limited [2]. We report a case of menopausal flushing successfully treated with a broadband light (BBL) and intradermal botulinum toxin (BTX) injections.

A written informed consent was obtained from the patient for the publication of this case report.

CASE REPORT

A 52-year-old female patient presented with a chief complaint of facial flushing (Fig. 1A). She had an unremarkable past medical history and had been treated with non-ablative radiofrequency, 1,064 nm neodymium-doped yttrium aluminum garnet laser, and BTX injections for skin wrinkles and tightening.

Figure 1. (A) Before the patient’s first treatment session. (B) After applying topical niacin cream to induce vasodilation.

The patient underwent three treatment sessions with an interval of 1 month. Before each treatment session, topical niacin cream (Simfle Stick 119; Simfle Stick Co., Ltd) was applied to the patient’s face for 20 minutes to induce vasodilatation of the superficial cutaneous vasculature (Fig. 1B). BBL (Joule®; Sciton) was then applied in the following sequence. First, a 590 nm filter was used to scan the face. A total of two passes were done with a fluence of 7 J/cm2, pulse duration of 20 ms, spot size of 1.5 × 4.5 cm2, and cooling crystal temperature of 15°C. Afterwards, a 565 nm filter with a fluence of 13 J/cm2, pulse duration of 20 ms, a spot size 1.5 × 4.5 cm2, and cooling crystal temperature of 20°C, was used to target erythema. Lastly, the SkinTyteTM (Sciton) constant motion technique was used on both cheeks and chin with an 800ST filter (Sciton), an intensity of 12 W/cm2, a pulse duration of 12 seconds, and a cooling crystal temperature of 25°C. The total accumulated energy was 20,000 J.

At the patient’s first treatment session, she was injected with BTX on both cheeks. A bottle of 200 U BTX (Clostridium botulinum toxin type A, Botulex Inj. 200 U; Hugel) was dissolved with 8.0 ml of normal saline and diluted to 2.5 U/0.1 ml. A 30-gauge insulin syringe was used, and the injection points were spaced 1 cm apart to cover the erythematous lesions in her cheeks. The total of 25 U was used, with 1.25 U (0.05 ml) injected each point.

After three treatment sessions, her facial flushing was reduced significantly (Fig. 2). Additionally, the patient was satisfied with the improvement in her facial tone and the reduction of facial flushing.

Figure 2. (A) At the second treatment session. (B) At the last treatment session, erythema of both cheeks was resolved.
DISCUSSION

Over the past 30 years, light-based devices have been widely used for facial redness and telangiectasia [4]. The most used laser modality for vascular lesions is a pulsed dye laser (PDL) with a wavelength of 585-595 nm. Intense pulsed light (IPL) treatment consists of a broadband spectrum of light sources, ranging from 500 to 1,200 nm, that targets vascular lesions using filters of specific wavelength cutoffs [5]. Lower cutoffs are effective in treating telangiectasias in the superficial dermis, beneficial in reducing facial background erythema [6]. Though both PDL and IPL displayed similar efficacy in reducing facial erythema [4,5,7], IPL provides some technical advantages, such as faster coverage and a lack of a consumable cooling technology (dye kit and cryogen spray cooling) [7]. Success in the treatment of erythema and telangiectasias using IPL has been widely documented [6]; Kassir et al. [6] used IPL with 420-530 nm cutoff filter and about 70% of rosacea patients had reduction in redness and flushing; Papageorgiou et al. [8] used IPL with 560 nm cutoff filter to successfully treat rosacea-related erythema and telangiectasia with minimal and self-limiting side effects. BBL is a multifunctional light and laser treatment system based on IPL that is widely used in clinical practice [7].

Since its Food and Drug Administration approval in 2002 for the treatment of dynamic wrinkles [7], BTX has become one of the most sought-after products in cosmetic rejuvenation [9]. Recent studies have shown that BTX may be effective in treating facial flushing and erythema [9,10]. BTX inhibits inflammation and vasodilation by blocking the release of neurotransmitters, such as acetylcholine, calcitonin gene-related peptide, vasoactive intestinal peptide, substance P, and glutamate, from the peripheral autonomic nerves of the skin’s vasodilator system [7,9-11]. Furthermore, BTX reduces erythema and flushing by inhibiting the expression of transient receptor potential ankyrin 1, which is downregulated by the soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) protein [7]. Lastly, mast cell degranulation is inhibited by cleaving the SNARE protein in mast cells, lessening cutaneous erythema [7,10]. Low et al. [12] found that skin blood flow and cutaneous vascular conductance during a menopausal hot flash are blocked by BTX, proving that elevations in skin blood flow during hot flashes are predominantly neurally mediated via sympathetic cholinergic nerves. This finding explains why BTX was effective in improving the patient’s facial erythema and the severity of sudden flushing.

Flushing is a visible symptom of increased cutaneous blood flow, and is restricted to areas with more visible superficial cutaneous vasculature and higher erythrocyte counts [3]. Due to the brief and episodic nature of flushing, it is possible that patients may not present with erythema during their laser treatment sessions, making it difficult to set targeted treatment areas [3,13-15]. Several methods for artificially causing flushing, such as hyperthermic stimulation using hair dryers, exercising, overdressing, and ingesting triggering foods and beverages, have been proposed [14]. However, the cooling devices used during laser treatment cause vasoconstriction, leading to a decrease in oxyhemoglobin levels, the target chromophore [13-15]. In this study, topical niacin cream was used to magnify facial erythema (Fig. 1B). Niacin induces cutaneous vasodilation and increases blood flow by releasing prostaglandins from keratinocytes. As a result, greater filling with chromophores within targeted blood vessels led to greater bearing of heat energy and subsequent vascular damage [13].

Menopausal hot flashes are believed to occur due to the physiologic narrowing of the hypothalamic thermoregulatory system in response to estrogen deprivation, leading to a rapid rise in body temperature along with vasodilation [2]. Hormonal therapy remains the treatment of choice, but its use is limited due to the increased risk of cardiovascular disease, venous thromboembolism, and breast cancer [1]. Most nonhormonal therapies for menopausal symptoms are based on lifestyle modifications, and there is a lack of studies on the use of energy-based devices [2]. This study used both BBL and BTX in the management of the patient’s facial erythema. Moreover, a decrease in the incidence of sudden facial flushing, and improved facial tone were also observed. Further studies comparing various energy-based modalities, and its efficacy compared to existing pharmacological treatments, are necessary.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: SJL. Resources: SJL. Project administration: SJL, HKC. Supervision: SJL, HKC. Visualization: SJL, JL. Writing–original draft: JL. Writing–review & editing: all authors.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

DATA AVAILABILITY

None.

References
  1. Pinkerton JV. Hormone therapy for postmenopausal women. N Engl J Med 2020;382:446-55.
    Pubmed CrossRef
  2. Santoro N, Roeca C, Peters BA, Neal-Perry G. The menopause transition: signs, symptoms, and management options. J Clin Endocrinol Metab 2021;106:1-15.
    Pubmed CrossRef
  3. Lee SJ, Roh MR, Lee SH, Chung WS, Lee JE, Oh SH, et al. Topical niacin cream-assisted 595-nm pulsed-dye laser treatment for facial flushing: retrospective analysis of 25 Korean patients. J Eur Acad Dermatol Venereol 2012;26:54-8.
    Pubmed CrossRef
  4. Tirico MCCP, Jensen D, Green C, Ross EV. Short pulse intense pulsed light versus pulsed dye laser for the treatment of facial redness. J Cosmet Laser Ther 2020;22:60-4.
    Pubmed CrossRef
  5. Chang HC, Chang YS. Pulsed dye laser versus intense pulsed light for facial erythema of rosacea: a systematic review and meta-analysis. J Dermatolog Treat 2022;33:2394-6.
    Pubmed CrossRef
  6. Kassir R, Kolluru A, Kassir M. Intense pulsed light for the treatment of rosacea and telangiectasias. J Cosmet Laser Ther 2011;13:216-22.
    Pubmed CrossRef
  7. Tong Y, Luo W, Gao Y, Liu L, Tang Q, Wa Q. A randomized, controlled, split-face study of botulinum toxin and broadband light for the treatment of erythematotelangiectatic rosacea. Dermatol Ther 2022;35:e15395.
    CrossRef
  8. Papageorgiou P, Clayton W, Norwood S, Chopra S, Rustin M. Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results. Br J Dermatol 2008;159:628-32.
    Pubmed CrossRef
  9. Park KY, Hyun MY, Jeong SY, Kim BJ, Kim MN, Hong CK. Botulinum toxin for the treatment of refractory erythema and flushing of rosacea. Dermatology 2015;230:299-301.
    Pubmed CrossRef
  10. Zhang H, Tang K, Wang Y, Fang R, Sun Q. Use of botulinum toxin in treating rosacea: a systematic review. Clin Cosmet Investig Dermatol 2021;14:407-17.
    Pubmed KoreaMed CrossRef
  11. Luque A, Rojas AP, Ortiz-Florez A, Perez-Bernal J. Botulinum toxin: an effective treatment for flushing and persistent erythema in rosacea. J Clin Aesthet Dermatol 2021;14:42-5.
  12. Low DA, Hubing KA, Del Coso J, Crandall CG. Mechanisms of cutaneous vasodilation during the postmenopausal hot flash. Menopause 2011;18:359-65.
    Pubmed KoreaMed CrossRef
  13. Kim TG, Roh HJ, Cho SB, Lee JH, Lee SJ, Oh SH. Enhancing effect of pretreatment with topical niacin in the treatment of rosacea-associated erythema by 585-nm pulsed dye laser in Koreans: a randomized, prospective, split-face trial. Br J Dermatol 2011;164:573-9.
    Pubmed CrossRef
  14. Kashlan L, Graber EM, Arndt KA. Hair dryer use to optimize pulsed dye laser treatment in rosacea patients. J Clin Aesthet Dermatol 2012;5:41-4.
  15. Cho SB, Lee SJ, Kang JM, Kim YK, Oh SH. Treatment of facial flushing by topical application of nicotinic acid cream followed by treatment with 595-nm pulsed-dye laser. Clin Exp Dermatol 2009;34:e405-6.
    Pubmed CrossRef


This Article


Cited By Articles
  • CrossRef (0)
  • Download (154)

Author ORCID Information

Services

Social Network Service

e-submission

Archives