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The treatment of digital ulcers has proven difficult in patients with severe Raynaud syndrome. It is always associated with an underlying autoimmune connective tissue disease, especially scleroderma, and often refractory to conventional therapies. Continuous, debilitating resting finger and hand pain and persistent ulcers prompted the exploration of alternative therapeutic options for a 52-year-old woman with treatment-resistant Raynaud syndrome.
The authors of this case report note that injection of 100 units of botulinum toxin A into the hand led to an immediate improvement in blood flow and pain, with eventual resolution of several digital ulcers. Although the exact mechanism by which botulinum toxin A exerts its effects in Raynaud syndrome has yet to be elucidated, the authors propose that it modulates expression of adrenergic receptors and neuropeptides, along with inhibiting contraction of vascular smooth muscle, thus improving tissue perfusion and pain.
Smith L et al. Botulinum toxin-A for the treatment of Raynaud syndrome. Arch Dermatol 2012 Apr; 148:426.
Comment
Botulinum toxin treatment of Raynaud syndrome has been previously reported in the hand and plastic surgery literature and once in the dermatology literature as a felicitous outcome in a patient being treated for hyperhidrosis, but this appears to be the first report of intended use in a U.S. dermatology journal. The mechanism of action of botulinum toxin A treatment is as unclear in Raynaud syndrome as it is in wound healing and migraine headaches. However, the empirical evidence is impressive. Given the outstanding safety of low doses of botulinum, there appears to be no harm in trying it as a first-line treatment for Raynaud syndrome. Further investigations may help clarify the most helpful and cost-effective injection points and dosages.