Turning Down the Fire: The Role of Botulinum Toxin Microdroplets in Refractory Rosacea Erythema

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Arash Babadjouni
Celine H Phong
Jodie Raffi
Natasha A Mesinkovska


Botulinum toxin A, Microdroplet, Rosacea, Refractory, Facial erythema, Neuromodulators, Flushing


Introduction: Dermal “micro-injections" of botulinum toxin A (BTX-A) treatment can improve facial flushing and erythema in patients with refractory rosacea. We present a case of a patient with longstanding papulo-pustular rosacea with flushing, refractory to laser, topical and systemic therapies, where intradermal microdroplet BTX-A injections successfully controlled erythema and flushing.

Case Description: A 49-year-old White female with a 4-year history of refractory papulo-pustular rosacea presented with bright, central facial erythema and telangiectasias after failing multiple 595 nm pulsed dye laser, topical (azelaic acid 15% gel, 0.025% tretinoin cream, and metrocream 0.75%) and systemic (isotretinoin 20 mg daily, spironolactone 25 mg daily and doxycycline 100 mg twice daily for 14 days) treatments. At treatment 1, 20 U of BTX-A was injected intradermally (0.05 mL of 1.25 IU/0.1 mL per microdroplet) to erythematous lesion. Treatment 2 was performed at her 4 week follow-up were we administer 15 U of BTX-A intradermally (0.05 mL of 1.25 IU/0.1 mL per microdroplet) . The patient was seen 4, 8, and 16 weeks after her second treatment were no BTX-A was administered due to a significant reduction in erythema and lasting results.

Discussion: Significant clinical improvement and patient satisfaction was achieved. No adverse events were reported after treatment aside from mild, localized injection site pain during the procedure. BTX-A administered as intradermal microdroplet injects can be a safe and efficacious option in the treatment of refractory rosacea erythema. Microbotox may be an effective adjunct, especially when topical and systemic therapies have failed. 


1. Hanna E, Xing L, Taylor JH, Bertucci V. Role of botulinum toxin A in improving facial erythema and skin quality. Archives of Dermatological Research. Published online 2021. doi:10.1007/s00403-021-02277-0

2. Zhu J, ji X, Xu Y, et al. The efficacy of intradermal injection of type A botulinum toxin for facial rejuvenation. Dermatologic Therapy. 2017;30(1). doi:10.1111/dth.12433

3. Kim MJ, Kim JH, Cheon HI, et al. Assessment of Skin Physiology Change and Safety after Intradermal Injections with Botulinum Toxin: A Randomized, Double-Blind, Placebo-Controlled, Split- Face Pilot Study in Rosacea Patients with Facial Erythema. Dermatologic Surgery. 2019;45(9). doi:10.1097/DSS.0000000000001819

4. Dayan SH, Pritzker RN, Arkins JP. A new treatment regimen for rosacea: onabotulinumtoxinA. Journal of Drugs in Dermatology. 2012;11(12).

5. Helfrich YR, Maier LE, Cui Y, et al. Clinical, histologic, and molecular analysis of differences between erythematotelangiectatic rosacea and telangiectatic photoaging. JAMA Dermatology. 2015;151(8). doi:10.1001/jamadermatol.2014.4728

6. Oh SH, Lee Y, Seo YJ, et al. The potential effect of botulinum toxin type A on human dermal fibroblasts: An in vitro study. Dermatologic Surgery. 2012;38(10). doi:10.1111/j.1524-4725.2012.02504.x