A new indication of botulinum toxin: leiomyoma-related pain

Piloleiomyoma Presented by Multiple Cutaneous Nodules: a Case Report

Introduction. Piloleiomyoma is a rare benign tumor which is caused by erector pili muscle and makes up 5% of all leiomyomas. They can be solitary and multiple. Multiple lesions still pose challenges for clinicians since their treatment option is very limited.

Case report. We report a case of a 25-year-old male patient who had painful papules and nodules on the neck and chest for three years. Multiple red-brown papules and nodules in the skin of regio mammaria dextra and regio submandibularis on the left were seen on physical examination. Histopathological examination of punch bi-were seen on physical examination. Histopathological examination of punch biopsy sample revealed well-circumscribed nodule composed of spindle cells. The case was reported as cutaneous leiomyoma (piloleiomyoma). The patient was given 5 mg/day amlodipin and kept under control.

Conclusion. The ideal treatment option for piloleiomyoma is surgical excision, but the problem with that treatment is that the lesions have tendency to recur. Medicamentous therapy plays a limited role; however, calcium-channel blockers and α-adrenergic blockers may help in palliating or eliminating associated pain through inhibition of smooth muscle contraction.

Alternative Clinical Indications of Botulinum Toxin

Botulinum toxin type A (BoNTA) is a powerful neurotoxin that inhibits acetylcholine release from presynaptic vesicles. The potency and safety profile of BoNTA grant the toxin vast therapeutic potential. It has been used off-label for a variety of dermatologic conditions. This review aims to analyze published literature regarding the benefits and risks of the off-label use of BoNTA beyond facial lines, including eccrine hidrocystomas, enlarged pores, keloids and hypertrophic scars, hidradenitis suppurativa, hyperhidrosis, masseter muscle hypertrophy, and salivary gland hypertrophy, among others. A MEDLINE search from January 2000 to December 2019 was conducted on the off-label uses of botulinum toxin in dermatology.

Solitary Piloleiomyoma in the Scalp

Cutaneous leiomyomas can be classified into three types according to the site of origin: piloleiomyoma, angioleiomyoma, and dartoic (genital) leiomyoma. It might be expected that leiomyomas are commonly found on the scalp because there are many arrector pili muscles and vessels. However, leiomyomas are actually rarely reported in the scalp. Recently, we observed a case of cutaneous leiomyoma in the scalp and present our experience along with a literature review.

A Case of Hereditary Leiomyomatosis and Renal Cell Carcinoma

A 49-year-old lady presented with multiple recurring painful lesions over her thighs, arms, and back. Past medical history included a left sided nephrectomy for renal cell carcinoma and a hysterectomy for multiple uterine fibroids (leiomyomas). Histopathological examination revealed changes consistent with pilar leiomyomas. Gene mutation analysis confirmed a diagnosis of hereditary leiomyomatosis and renal cell carcinoma. Hereditary leiomyomatosis and renal cell carcinoma is an uncommon autosomal dominant condition characterised by the concurrent presentation of cutaneous and uterine leiomyomas. Renal cell carcinoma associated with this condition is more aggressive and a significant cause of mortality. Due to this association with potentially fatal renal cell carcinoma we felt that it was important to highlight this case with an update on pathophysiology and management.

Efficacy of Intralesional Botulinum Toxin A for Treatment of Painful Cutaneous Leiomyomas: A Randomized Clinical Trial

IMPORTANCE

Cutaneous leiomyomas can be associated with severe paroxysmal pain in which nerve conduction may have a key role. Medical management of painful cutaneous leiomyomas is generally unsatisfactory.

OBJECTIVE

To assess the efficacy of intralesional botulinum toxin A in the management of pain associated with cutaneous leiomyomas.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, placebo-controlled pilot study conducted from January 5, 2009, to March 27, 2014. The setting was a single-center study at the National Institutes of Health among participants 18 years or older with cutaneous leiomyomas characterized by pain at least once weekly and pain of at least 4 on a pain scale ranging from 0 to 10.

INTERVENTIONS

Eighteen participants were randomized to receive intralesional botulinum toxin A (5 U per 1 cm2) or equivalent volumes of intralesional saline placebo.

MAIN OUTCOMES AND MEASURES

The primary outcomes were the differences in average lesional pain assessed by the Brief Pain Inventory and visual analog scale before and after ice provocation over a 4-week period.

RESULTS

No significant difference in average lesional pain was observed between the study arms. Decreased pain was reported in the botulinum toxin vs placebo arms by visual analog scale scores before ice provocation (median, 0.00; range, -3.30 to 0.70 for botulinum toxin and median, 0.40; range, -1.30 to 1.50 for placebo; P = .06); however, this finding was nonsignificant. No significant difference was observed in change in pain after ice provocation. A significant difference was seen between the arms in skin-related quality of life by total Dermatology Life Quality Index (median, -4.00; range, -8.00 to 2.00 for botulinum toxin and median, 0.00; range, -1.00 to 4.00 for placebo; P = .007) and with the specific skin pain-related question on the Dermatology Life Quality Index (median, -1.00; range, -2.00 to 1.00 for botulinum toxin and median, 0.00; range, -1.00 to 0.00 for placebo; P = .048). No significant difference was found in pain as ascertained by Patient Global Impression of Change at week 4. No serious adverse events related to botulinum toxin use were observed.

CONCLUSIONS AND RELEVANCE

The use of botulinum toxin to treat painful cutaneous leiomyomas was associated with improved quality of life and with a trend toward improved pain at rest.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00971620.

Zosteriform cutaneous leiomyoma-Type II: An uncommon presentation

Cutaneous leiomyomas are rare, benign smooth muscle tumors, characterized by painful nodules in most of the cases. They can occur in multiple disseminated, segmental or zosteriform and solitary forms. Segmental or zosteriform leiomyoma can occur either alone (Type I), or with scattered nonsegmental lesions elsewhere (Type II); the latter variety occurring rarely. Here we present a case of Type II zosteriform leiomyoma in a middle aged individual.

[Plaque-like leiomyomas on a chemical burn: First case report]

BACKGROUND

Cutaneous leiomyomas are uncommon benign smooth muscle neoplasms of skin of unknown pathogenesis. We report a sporadic case of multiple cutaneous leiomyomas at the site of a chemical burn.

OBSERVATION

A 47-year-old male presented with multiple grouped red nodules on the right calf painful to cold and to touch. The lesions were located on the site of a chemical wound that had occurred 5 years earlier. Histopathological examination revealed a proliferation of smooth muscle fibres, leading to diagnosis of leiomyoma.

DISCUSSION

To our knowledge, the literature contains no previous reports of sporadic multiple cutaneous leiomyomas occurring at a chemical burn site. While a chance association cannot be ruled out, there is also the possibility of a physiopathological mechanism similar to that of vascular tumours following exposure to 4-hydrazinobenzoic acid. This compound, a hydrazine derivative of the fungus Agaricus bisporus, can cause smooth-muscle tumours in the aorta and large vessels with morphological characteristics similar to those seen in vascular leiomyomas.

Aesthetic uses of the botulinum toxin

The cosmetic use of botulinum toxin (BoNT) is the most common cosmetic procedure performed in the world today. Common adverse events seen in the aesthetic use of the BoNT include swelling, localized bruising, headaches, injection site discomfort, excessive muscle weakness, and unintended paresis of adjacent muscles. BoNT has a wide array of cosmetic uses, including treatment of glabellar lines, chemical browlift, forehead wrinkles, periorbital, and perioral lines. The future formulations and applications of BoNT type A will be plentiful, and are exciting to consider.

Dermoscopy as an adjuvant tool for detecting skin leiomyomas in patient with uterine fibroids and cerebral cavernomas

Background

Hereditary syndromes frequently need the cooperation of different specialties to increase diagnostic competence. Multiple cutaneous and uterine leiomyomatosis syndrome is a rare autosomal dominant disorder caused by the mutations of the fumarate hydratase gene, demonstrated in 80 to 100 percent of affected individuals. This can be linked to an increased risk of renal cancer in both sexes. The skin involvement is described to highlight the diagnostic role of the cutaneous counterpart in identifying this rare syndrome.

Case presentation

A 37-year-old woman suffering from several uterine fibroids presented multiple, painful, papulo-nodules on her left subscapular side, both forearms and legs. The patient underwent surgery on six lesions: five were leiomyomas, whilst one was a dermatofibroma. Genetic sequencing did not evidence known fumarate hydratase gene mutations. Dermoscopy showed a brown delicate pigmented network and included leiomyomas among the non-melanocytic benign skin tumours featuring a dermatofibroma-like pattern. Abdominal computerized-tomography scan did not reveal renal cancer, but brain magnetic resonance imaging showed one asymptomatic cerebral cavernoma. The patient benefited from the surgical removal of the five larger cutaneous lesions and from gabapentin, which relieved her pain.

Conclusions

This observation highlights the usefulness of dermoscopy in the diagnosis of cutaneous leiomyomas disclosing multiple cutaneous and uterine leiomyomatosis syndrome. Dermoscopy should be performed for non-melanocytic multiple lesions mimicking leiomyomas in a large number of patients, to establish a strict classification and identify false negative cases or evaluate them as dermatofibromas. In this case, the dermatologist recognized the risk of renal cancer and cerebral cavernomas.

Gene therapy: a potential approach for cancer pain

Chronic pain is experienced by as many as 90% of cancer patients at some point during the disease. This pain can be directly cancer related or arise from a sensory neuropathy related to chemotherapy. Major pharmacological agents used to treat cancer pain often lack anatomical specificity and can have off-target effects that create new sources of suffering. These concerns establish a need for improved cancer pain management. Gene therapy is emerging as an exciting prospect. This paper discusses the potential for viral vector-based treatment of cancer pain. It describes studies involving vector delivery of transgenes to laboratory pain models to modulate the nociceptive cascade. It also discusses clinical investigations aimed at regulating pain in cancer patients. Considering the prevalence of pain among cancer patients and the growing potential of gene therapy, these studies could set the stage for a new class of medicines that selectively disrupt nociceptive signaling with limited off-target effects.

Skin and breast disease in the differential diagnosis of chest pain

There are several skin and breast lesions that can cause pain or tenderness. In most cases the presence of a skin lesion, if not its definitive diagnosis, will be clinically evident. In most instances treatment of these painful skin lesions is by simple excision, which will also provide histologic confirmation of the diagnosis. It would be rare for a cutaneous cause of skin pain to be mistaken for another cause. The prodromal pain of herpes zoster is most likely to cause diagnostic confusion. The painful skin lesions are usually identified by the patient as being the source of their discomfort. The specific diagnosis may not be apparent without submission of lesional tissue for histology. Chest pain is an uncommon presenting symptom of benign and malignant breast lesions. Breast examination and investigation may be appropriate when other causes of chest pain are not evident.