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Jung I, Kravitz S, Linabury J. Hereditary cold-induced palmar erythema with dysesthesia: A novel entity with response to onabotulinumtoxinA injections. JAAD Case Rep 2024; 51:56-58. [PMID: 39165632 PMCID: PMC11334728 DOI: 10.1016/j.jdcr.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024] Open
Affiliation(s)
- Injae Jung
- School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Shena Kravitz
- Department of Dermatology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - John Linabury
- Department of Dermatology, Walter Reed National Military Medical Center, Bethesda, Maryland
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Gronbeck C, Beltrami EJ, Jain N, Hargis G, Sloan B, Cook BL, Grant-Kels JM, Feng H. Surface anatomy in dermatology: Part II-Impact on perioperative management, procedural technique, and cosmesis. J Am Acad Dermatol 2024; 91:223-240. [PMID: 37429437 DOI: 10.1016/j.jaad.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/27/2023] [Accepted: 07/02/2023] [Indexed: 07/12/2023]
Abstract
This CME series reviews updated Delphi consensus surface anatomy terminology through the lens of common medical and procedural dermatology scenarios, helping to underscore high-yield points that can be readily integrated into clinical practice to support patient care. Part I of the series reviewed the current state of standardized surface anatomy, provided an illustrative review of consensus terminology, highlighted prominent landmarks that can aid in critical diagnoses, and related the importance of precise terminology to principles of medical management. Part II will utilize consensus terminology to heighten recognition of key landmarks in procedural dermatology to support optimal functional and aesthetic outcomes.
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Affiliation(s)
- Christian Gronbeck
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut
| | - Eric J Beltrami
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Neelesh Jain
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut
| | - Geneva Hargis
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Brett Sloan
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut; VA Connecticut Healthcare System, West Haven, Connecticut
| | - Bernard L Cook
- University of Connecticut School of Medicine, Farmington, Connecticut
| | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut; Department of Dermatology, the University of Florida College of Medicine, Gainesville, Florida
| | - Hao Feng
- Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut.
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Vasella M, Wolf S, Grünherz L, Kim BS, Lindenblatt N, Giovanoli P, Gousopoulos E. Evaluation of the Effect of Botulinum Toxin A on the Lymphatic Endothelial Cells. Aesthetic Plast Surg 2024:10.1007/s00266-024-04061-7. [PMID: 38839615 DOI: 10.1007/s00266-024-04061-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/09/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Botulinum toxin A (BoTA) is a neurotoxin formed by Clostridium botulinum, with a broad medical application spectrum. While the primary effect of BoTA is on the muscles, the effects of BoTA in other systems including the blood vasculature have already been examined, revealing unexpected actions. However, no studies exist to the best of our knowledge regarding the potential effects of BoTA on the lymphatic vascular system, possessing a critical role in health and disease. Isolated human lymphatic endothelial cells (LECs) were cultured in dedicated in vitro culture systems. The analysis including imaging and cell culture approaches as well as molecular biology techniques is performed to examine the LEC alterations occurring upon exposure to different concentrations of BoTA. MATERIALS AND METHODS Human LECs were cultured and expanded on collagen-coated petri dishes using endothelial basal medium and the commercial product Botox from Allergan as used for all our experiments. Harvested cells were used in various in vitro functional tests to assess the morphologic and functional properties of the BoTA-treated LECs. Gene expression analysis was performed to assess the most important lymphatic system-related genes and pathways. RESULTS Concentrations of 1, 5 or 10 U of BoTA did not demonstrate a significant effect regarding the proliferation and migration capacity of the LECs versus untreated controls. Interestingly, even the smallest BoTA dose was found to significantly decrease the cord-like-structure formation capacity of the seeded LECs. Gene expression analysis was used to underpin possible molecular alterations, suggesting no significant effect of BoTA in the modification of gene expression versus the starvation medium control. CONCLUSION LECs appear largely unaffected to BoTA treatment, with an isolated effect on the cord-like-structure formation capacity. Further work needs to assess the effect of BoTA on the smooth-muscle-cell-covered collecting lymphatic vessels and the possible aesthetic implications of such an effect, due to edema formation. LEVEL OF EVIDENCE V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Mauro Vasella
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Stefan Wolf
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Lisanne Grünherz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Epameinondas Gousopoulos
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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Sigamoney KV, Naji S, Hassan Z, McArthur P. Use of Botulinum Toxin Injections in the Treatment of Cold Intolerance. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:415-417. [PMID: 38817774 PMCID: PMC11133842 DOI: 10.1016/j.jhsg.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/18/2024] [Indexed: 06/01/2024] Open
Abstract
There is currently no consensus on the treatment of cold intolerance in extremities in post-trauma patients. We aim to present two cases where botulinum toxin type A injections were used to improve symptoms of cold intolerance. Botulinum toxin type A (Allergan) was injected into the area around the palmar digital neurovascular bundle on both sides of the affected finger. We performed this in two patients, and both had good improvement of symptoms. One patient was discharged, and the other remained under routine follow-up with potential yearly botulinum injections to aid symptoms during the winter months. Both patients are pleased with their outcomes and report significant improvement from the low-risk treatment. In both described cases, injections of botulinum toxin had a significant effect on their symptoms. We conclude that botulinum toxin type A may be used as a treatment modality to improve symptoms of cold intolerance after trauma.
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Penchev P, Dobrev V, Petrov PP, Hyusein R, Velchev V, Georgiev K. Botulinum Toxin Type A in the Treatment of Raynaud's Syndrome: A Case Report. Cureus 2024; 16:e57327. [PMID: 38690447 PMCID: PMC11060183 DOI: 10.7759/cureus.57327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2024] [Indexed: 05/02/2024] Open
Abstract
Raynaud's syndrome is characterized by paroxysmal vasospasm in the digital arterioles, following exposure to cold or stress. Pain, swelling, stiffness, and hypoesthesia are observed as manifestations. The presence of a trophic ulcer is accompanied by a range of severe manifestations. The assaults occur in three distinct phases, namely vasospastic, plethoric, and erythema. Various approaches improve the overall well-being of a patient. It is possible to differentiate between primary and secondary Raynaud's syndrome, the latter being linked to systemic diseases. The application of botulin toxin is commonly indicated in several medical conditions including focal dystonia, spasticity with or without contractures, paraparesis in children with cerebral palsy, multiple sclerosis, brain injuries, involuntary muscle hyperactivity of a non-dystonic nature, pain management, strabismus, nystagmus, sialorrhea, and esthetic medicine. When treating Raynaud's a technique is used with injection at the base of each finger, from the palmar side, which helps with cooling and minimizing discomfort for patients. We present a clinical case of a 70-year-old female patient with Raynaud's syndrome in which we have placed 70E distributed to both hands botulin toxin type A. Improvement in the patient's symptomatology was noticed on day 3, with warming of the hands, lack of swelling, and pain with duration of the effect little over three months. The patient underwent a six-month follow-up following the therapy with botulinum toxin type A, and no indications of recurrence or advancement of Raynaud's syndrome (RS) were seen.
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Affiliation(s)
- Plamen Penchev
- Faculty of Medicine, Medical University of Plovdiv, Plovdiv, BGR
| | - Valentin Dobrev
- Department of Neurology, Medical Center "VIP", Targovishte, BGR
| | - Petar-Preslav Petrov
- Department of Anatomy, Histology and Embryology, Medical University of Plovdiv, Plovdiv, BGR
| | - Remzi Hyusein
- Faculty of Medicine, Medical University of Sofia, Sofia, BGR
| | | | - Kristiyan Georgiev
- Clinic of Neurology, University Multiprofile Hospital for Active Treatment (UMHAT) Saint Marina, Varna, BGR
- Department of Neurology and Neuroscience, Medical University of Varna, Varna, BGR
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Curtiss P, Svigos K, Schwager Z, Lo Sicco K, Franks AG. Part II: The treatment of primary and secondary Raynaud's phenomenon. J Am Acad Dermatol 2024; 90:237-248. [PMID: 35809802 DOI: 10.1016/j.jaad.2022.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/15/2022] [Accepted: 05/25/2022] [Indexed: 10/17/2022]
Abstract
Raynaud phenomenon (RP) presents with either primary or secondary disease, and both have the potential to negatively impact patient quality of life. First-line management of RP should include lifestyle modifications in all patients. Some patients with primary RP and most with secondary RP require pharmacologic therapies, which may include calcium channel blockers, topical nitrates, phosphodiesterase 5 inhibitors, or endothelin antagonists. Additional approaches to treatment for those with signs of critical ischemia or those who fail pharmacologic therapy include botulinum toxin injection and digital sympathectomy. Herein, we describe in detail the treatment options for patients with RP as well as provide treatment algorithms for each RP subtype.
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Affiliation(s)
- Paul Curtiss
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Katerina Svigos
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Zachary Schwager
- Department of Dermatology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Kristen Lo Sicco
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York.
| | - Anrdew G Franks
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York; Division of Rheumatology, Department of Internal Medicine, New York University Grossman School of Medicine, New York, New York
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Norheim AJ, Borud E, Mercer JB, de Weerd L, Weiss T, Wilsgaard T. Botulinum Toxin A in the treatment of frostbite sequelae - results from a blinded, early-phase, comparative trial. Int J Circumpolar Health 2023; 82:2189556. [PMID: 36919578 PMCID: PMC10026811 DOI: 10.1080/22423982.2023.2189556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Freezing Cold Injuries (FCI) have been associated with long-term sequelae including vasospasm. The aims of the pilot study are to explore the research methodology and investigate the tolerability and safety of treatment with Botulinum Toxin-A (BTX-A) in FCI Sequelae. METHODOLOGY This pilot study tests the logistics, the treatment setting and the follow-up procedure in an early-phase, double-blinded, randomized, controlled trial study-design. The variables in the study were subjective symptoms, peripheral micro-vascularization/rewarming, somatosensory responsiveness, and generic measure of health status. RESULTS No major challenges or difficulties were noticed according to the protocol or the study methodology. The monitoring of tolerability and safety of treatment with BTX-A did not reveal any major unwanted and/or adverse reactions among the patients in the pilot study and no challenges occurred during data collection of endpoints. The study revealed an inaccuracy of the 2nd degree FCI diagnosis and uncover a need for relevant and sufficient clinical information for FCI classification. CONCLUSIONS This pilot study showed the study methodology with minor adjustments is feasible in a future full-scale clinical trial. The recruitment process needs to be more refined to ensure that the eligible study participants are a homogenous group of FCI patients.
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Affiliation(s)
- Arne Johan Norheim
- National Research Centre of Complementary and Alternative Medicine (NAFKAM), Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Einar Borud
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - James Brian. Mercer
- Medical Imaging Group. Institute for Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Louis de Weerd
- Department of Plastic Surgery and Hand Surgery, University Hospital of North Norway, Tromsø, Norway
| | - Thomas Weiss
- Clinical Psychology, Jena University, Jena, Germany
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Yu F, Liu Y, Zhang C, Pang B, Zhang D, Zhao W, Li X, Yang W. Efficacy analysis of minimally invasive surgery for Raynaud's syndrome. BMC Surg 2023; 23:313. [PMID: 37838733 PMCID: PMC10576400 DOI: 10.1186/s12893-023-02225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/08/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Raynaud's syndrome (RS), also referred to as Raynaud's phenomenon, is a vasospastic disorder causing episodic color changes in extremities upon exposure to cold or stress. These manifestations, either primary Raynaud's phenomenon (PRP) or associated with connective tissue diseases like systemic sclerosis (SSc) as secondary Raynaud's phenomenon (SRP), affect the quality of life. Current treatments range from calcium channel blockers to innovative surgical interventions, with evolving efficacy and safety profiles. METHODS In this retrospective study, patients diagnosed with RS were selected based on complete medical records, ensuring homogeneity between groups. Surgeries involved microscopic excision of sympathetic nerve fibers and stripping of the digital artery's adventitia. Postoperative care included antibiotics, analgesia, oral nifedipine, and heat therapies. Evaluation metrics such as the VAS pain score and RCS score were collected bi-weekly. Data analysis was conducted using SPSS 26.0, with significance set at p < 0.05. RESULTS In total, 15 patients formed the experimental group, with five presenting fingertip soft tissue necrosis and ten showing RS symptoms. Comparative analysis of demographic data between experimental and control groups, both containing 15 participants, demonstrated no significant age and gender difference. However, the "Mean Duration of RP attack" in the experimental group was notably shorter (9.47 min ± 0.31) than the control group (19.33 min ± 1.79). The RS Severity Score also indicated milder severity for the experimental cohort (score: 8.55) compared to the control (score: 11.23). Postoperative assessments at 2, 4, and 6 weeks revealed improved VAS pain scores, RCS scores, and other measures for the experimental group, showing significant differences (p < 0.05). One distinctive case showcased a variation in the common digital nerve and artery course in an RS patient. CONCLUSION Our retrospective analysis on RS patients indicates that microsurgical techniques are safe and effective in the short term. As surgical practices lean towards minimally invasive methods, our data supports this shift. However, extensive, prospective studies are essential for conclusive insights.
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Affiliation(s)
- Fengwei Yu
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Yongtao Liu
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China.
| | - Chengnian Zhang
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Botao Pang
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Daijie Zhang
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Wei Zhao
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Xuecheng Li
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Weiqiang Yang
- The First Clinical School of Binzhou Medical University, Binzhou, 256600, China
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Lawson O, Sisti A, Konofaos P. The Use of Botulinum Toxin in Raynaud Phenomenon: A Comprehensive Literature Review. Ann Plast Surg 2023; 91:159-186. [PMID: 37450876 DOI: 10.1097/sap.0000000000003603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Raynaud phenomenon (RP) is a vasospastic condition of the digits that can be primary or secondary to systemic disease. Symptoms are triggered by cold or stress and can cause pain and skin color changes. The chronic ischemia may lead to necrosis, ulceration, and amputation. There are no Food and Drug Administration-approved treatments and cases refractory to pharmacologic and surgical treatments are difficult to control. Local botulinum toxin injections have been increasingly used in the treatment of Raynaud disease and have shown promising results. AIM OF THE STUDY To examine the outcomes, techniques, and complications of botulinum toxin use for the treatment of Raynaud disease. METHODS The PubMed database was queried using "botulinum toxin" AND "Raynaud phenomenon" as title key words. Preferred reporting items for systematic reviews and meta-analysis criteria were used. Additional articles were selected while reviewing the references of the articles from PubMed. No time restrictions were followed. Articles of all languages were included. Articles were analyzed for study type, demographics, diagnosis/inclusion criteria, treatment methods, outcome measures, length of follow-up, results, and complications. A positive outcome was defined as subjective improvement in symptoms and/or improvement in the outcome measures. A poor outcome was defined as harm done to the patient by the injection that would not have occurred otherwise. RESULTS Forty-two clinical studies describing the use of botulinum toxin for Raynaud's phenomenon were found. A total of 425 patients with primary or secondary Raynaud's were treated, with ages ranging from 14 to 91 years. There were 342 women and 81 men, with a female-to-male ratio of 38:9. Outcomes were positive in 96.2% of patients. There were 14.2% of the studies that reported 3.5% of all patients showing no subjective improvement. A single study reported a poor outcome for 1 patient. There were 40.5% of the studies that reported complications, affecting 20.2% of all patients. The most frequently reported complication was transient hand weakness, affecting 44.2% of patients with complications and 8.9% of total patients. Weakness resolved in hours to months after injection. Pain at the injection site lasting minutes to days was reported in 40.7% of patients with complications, and 8.2% of total patients. CONCLUSIONS Botulinum toxin treatment for RP is effective. Complications are minor and self-limiting.
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Affiliation(s)
- Olivia Lawson
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN
| | - Andrea Sisti
- Division of General Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
- Shriners Hospital for Children, Galveston, TX
| | - Petros Konofaos
- Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
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Senet P, Maillard H, Diot E, Lazareth I, Blaise S, Arnault JP, Pistorius MA, Boulon C, Cogrel O, Warzocha U, Rivière S, Malloizel-Delaunay J, Servettaz A, Sassolas B, Viguier M, Monfort JB, Janique S, Vicaut E. Efficacy and Safety of Botulinum Toxin in Adults with Raynaud's Phenomenon Secondary to Systemic Sclerosis: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Study. Arthritis Rheumatol 2023; 75:459-467. [PMID: 36066501 DOI: 10.1002/art.42342] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/10/2022] [Accepted: 08/31/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To determine whether a single session of botulinum toxin type A (BTA) injections into both hands more effectively decreases the frequency of systemic sclerosis-associated Raynaud's phenomenon (SSc-RP) episodes than placebo. METHODS This multicenter, randomized, double-blind, placebo-controlled, parallel-group phase III trial in patients with SSc-RP assessed the effect of 50-unit BTA or placebo injections into the palms of both hands around each neurovascular bundle during 1 session in winter. The primary end point was the between-group difference in the median change in the number of RP episodes from baseline (day 0) to 4 weeks postinjection. Values between the groups were compared with the Wilcoxon rank-sum test. RESULTS The intent-to-treat analysis included 46 BTA-treated patients and 44 placebo recipients. At 4 weeks after assigned treatment injections, the median number of daily RP episodes decreased comparably in the BTA and placebo groups (median change -1 episode/day [interquartile range (IQR) -1.5, 0 episodes/day] and -1 episode/day [IQR -2.5, 0 episodes/day], respectively) (P = 0.77 versus placebo). Moreover, change in Raynaud's Condition Score, quality of life assessed by Health Assessment Questionnaire disability index, and hand function assessed by shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Cochin Hand Function Scale from baseline to follow-up weeks 4, 12, and 24 did not differ significantly between groups. The BTA group experienced transient hand muscle weakness significantly more frequently (P = 0.003). CONCLUSION Neither the primary nor secondary end points were reached, and our results do not support any beneficial effect of palmar BTA injections to treat SSc-RP.
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Affiliation(s)
- Patricia Senet
- Assistance Publique-Hôpitaux de Paris, and Service de Dermatologie, Centre Hospitalier Universitaire Tenon, Groupe Hospitalier Sorbonne Université, Paris, France
| | - Hervé Maillard
- Service de Dermatologie, Centre Hospitalier Le Mans, Le Mans, France
| | - Elisabeth Diot
- Service de Médecine Interne et Immunologie Clinique, Centre Hospitalier Universitaire Bretonneau-Tours, Tours, France
| | | | - Sophie Blaise
- Université Grenoble Alpes, Inserm, HP2, Grenoble, France
| | - Jean-Philippe Arnault
- Service de Dermatologie, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
| | | | - Carine Boulon
- Service de Médecine Vasculaire, Centre Hospitalier Universitaire St-André, Bordeaux, France
| | - Olivier Cogrel
- Unité de Dermatologie Interventionnelle, Service de Dermatologie, Centre Hospitalier Universitaire, Bordeaux, France
| | - Ursula Warzocha
- Assistance Publique-Hôpitaux de Paris, and Service de Médecine Interne, Centre Hospitalier Universitaire Avicenne, Bobigny, France
| | - Sébastien Rivière
- Assistance Publique-Hôpitaux de Paris, and Service de Médecine Interne, Centre Hospitalier Universitaire Saint-Antoine, Groupe Hospitalier Sorbonne Université, Paris, France
| | | | - Amélie Servettaz
- Service de Médecine Interne, Maladies Infectieuses, Immunologie Clinique, Hôpital Robert-Debré, Centre Hospitalier Universitaire, Reims, France
| | - Bruno Sassolas
- Département de Médecine Interne et Pneumologie, Hôpital de la Cavale Blanche, Centre Hospitalier Régional Universitaire, Brest, France
| | - Manuelle Viguier
- Service de Dermatologie-Vénéréologie, Hôpital Robert-Debré, Université Reims Champagne Ardenne, IRMAIC, EA7509, Reims, France
| | - Jean-Benoit Monfort
- Assistance Publique-Hôpitaux de Paris, and Service de Dermatologie, Centre Hospitalier Universitaire Tenon, Groupe Hospitalier Sorbonne Université, Paris, France
| | - Solène Janique
- Assistance Publique-Hôpitaux de Paris, Unité de Recherche Clinique, Centre Hospitalier Universitaire Fernand-Widal, Paris, France
| | - Eric Vicaut
- Assistance Publique-Hôpitaux de Paris, Unité de Recherche Clinique, Centre Hospitalier Universitaire Fernand-Widal, Paris, France
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Greene BHC, Gudimella R, Corkum JP, Boone H, Samargandi OA, Williams J. Managing cold intolerance after hand injury: A systematic review. HAND SURGERY & REHABILITATION 2023; 42:109-114. [PMID: 36720347 DOI: 10.1016/j.hansur.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/30/2023]
Abstract
OBJECTIVES This systematic review seeks to understand whether cold intolerance (CI) improves with time and if there is any role for management strategies such as behavioural therapy, surgery, or pharmacotherapy. METHODS Two independent reviewers used a predefined search strategy to query MEDLINE, PubMed, Embase, CINAHL, Cochrane Library, Web of Science and Google Scholar databases. Articles written in English, Studies of interventions (such as pharmacotherapy or behavioural therapy) for cold intolerance in adult patients with a history of hand injury along with prevalence over time were included for review. RESULTS Seventeen studies were included, with twelve prognostic studies of the effect of time on CI, four studies of self management/behavioural therapies, and a single study of surgical treatment of neuromas. No studies of pharmacotherapies were identified for inclusion in the hand injury literature. Most studies (76.4%) were either prevalence or prospective cohort studies; no level I or II evidence studies were included. CONCLUSIONS Cold intolerance does not resolve over time for the vast majority of patients. Behavioral and self-management studies have low efficacy and studies presented had a high risk of bias. There is a lack of evidence for the use of pharmacotherapy in CI and this could be considered for future studies.
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Affiliation(s)
- Bradley H C Greene
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Rakesh Gudimella
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Joseph P Corkum
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hannah Boone
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Osama A Samargandi
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Surgery, King Abduaziz University, Jeddah, Saudi Arabia
| | - Jason Williams
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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12
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Ayala G. Neuroepithelial Interactions in Cancer. ANNUAL REVIEW OF PATHOLOGY 2023; 18:493-514. [PMID: 36323005 DOI: 10.1146/annurev-pathmechdis-031521-023248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nerves not only regulate the homeostasis and energetic metabolism of normal epithelial cells but also are critical for cancer, as cancer recapitulates the biology of neural regulation of epithelial tissues. Cancer cells rarely develop in denervated organs, and denervation affects tumorigenesis, in vivo and in humans. Axonogenesis occurs to supply the new malignant epithelial growth with nerves. Neurogenesis happens later, first in ganglia around organs or the spinal column and subsequently through recruitment of neuroblasts from the central nervous system. The hallmark of this stage is regulation of homeostasis and energetic metabolism. Perineural invasion is the most efficient interaction between cancer cells and nerves. The hallmark of this stage is increased proliferation and decreased apoptosis. Finally, carcinoma cells transdifferentiate into a neuronal profile in search of neural independence. The latter is the last stage in neuroepithelial interactions. Treatments for cancer must address the biology of neural regulation of cancer.
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Affiliation(s)
- Gustavo Ayala
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at Houston, McGovern School of Medicine, Houston, Texas, USA;
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13
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Regli IB, Strapazzon G, Falla M, Oberhammer R, Brugger H. Long-Term Sequelae of Frostbite-A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189655. [PMID: 34574580 PMCID: PMC8465633 DOI: 10.3390/ijerph18189655] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/02/2021] [Accepted: 09/06/2021] [Indexed: 11/16/2022]
Abstract
Frostbite is tissue damage caused by freezing temperatures and constitutes an important cause of morbidity in cold climate zones and high altitude. The direct effects of sub-zero temperatures lead to tissue freezing, electrolyte shifts and pH alterations, microvascular damage, and eventually to cell death. Upon rewarming, inflammatory reperfusion injury and thrombosis may lead to further tissue damage. Several studies and various case reports show that many patients suffer from long-term sequelae such as vasomotor disturbances (associated with susceptibility to refreezing), and neuropathic and nociceptive pain, as well as damage to skeletal structures. There are still many uncertainties regarding the pathophysiology of these sequelae. It has been shown that the transient receptor potential channel (TRP) family plays a role in cold allodynia. Botulinum Toxin type A (BTX-A) injections have been reported to be beneficial in vasomotor and neuropathic disturbances secondary to frostbite. Epidural sympathetic block has been used for short-term treatment of frostbite induced chronic pain. Furthermore, amitriptyline, gabapentinoids, and duloxetine may have some benefits. Frostbite arthritis clinically resembles regular osteoarthritis. In children there is a risk of epiphyseal cartilage damage leading to bone deformities. Despite some promising therapeutic concepts, the scarcity of data on frostbite long-term sequelae in the literature indicates the need of more in-depth studies of this pathology in all its aspects.
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Affiliation(s)
- Ivo B. Regli
- Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy; (G.S.); (M.F.); (H.B.)
- Department of Anaesthesia and Intensive Care, “F. Tappeiner” Hospital, 39012 Merano, Italy
- Correspondence: ; Tel.: +39-0471-055-863
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy; (G.S.); (M.F.); (H.B.)
- Department of Anaesthesia and Intensive Care, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Marika Falla
- Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy; (G.S.); (M.F.); (H.B.)
- Center for Mind/Brain Sciences, University of Trento, 38123 Rovereto, Italy
| | - Rosmarie Oberhammer
- Department of Anaesthesia and Intensive Care, Hospital of Brunico, 39031 Brunico, Italy;
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, Eurac Research, 39100 Bolzano, Italy; (G.S.); (M.F.); (H.B.)
- Department of Anaesthesia and Intensive Care, Medical University Innsbruck, 6020 Innsbruck, Austria
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14
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Abstract
BACKGROUND Raynaud's phenomenon (RP) is a clinical syndrome characterized by recurrent episodes of digital vasospasm triggered by exposure to physical and chemical agents or emotional stress. Although many pharmacologic treatments have been tested, there is still no cure or gold standard therapy. Botulinum toxin treatment has been proved to reduce pain and increase arterial blood flow in treated hands of adult patients with RP. OBJECTIVE The aim of this study is to evaluate the efficacy of botulinum toxin A on younger than 18-year-old patients with primary and secondary RP. MATERIALS AND METHODS A single-center prospective study was performed, including 8 patients aged 14 to 17 years who were clinically diagnosed with primary or secondary RP. BTX was injected into each hand without sedation or anesthetic blockade. The primary outcome was pain reduction after BTX injection. Pain intensity was evaluated at baseline and in the first follow-up. Secondary outcomes included variations in the number and severity of RP episodes after the BTX injection. RESULTS All patients stated significant pain reduction and decreased cold sensitivity, except one patient who did not feel any changes. No patients reported any loss of strength on thumb-index finger. CONCLUSION BTX injection is a simple, noninvasive, and cost-effective treatment alternative, offering an important nonsurgical therapeutic option for the pediatric population. It could also help optimize the dose of other treatments used in these patients. The most commonly observed positive effect is a reduction in the pain associated with RP attacks. Further studies are needed to confirm these results.
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15
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Klein-Weigel P, Sander O, Reinhold S, Nielitz J, Steindl J, G. Richter J. Raynaud's Phenomenon: A Vascular Acrosyndrome That Requires Long-Term Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0023. [PMID: 33632387 PMCID: PMC8287761 DOI: 10.3238/arztebl.m2021.0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Some 5-10% of the German population are affected by Raynaud's phenomenon (RP). In around 10-20% of cases RP arises from an underlying disease, most commonly a connective tissue disease. This review encompasses the diagnosis and differential diagnosis of RP and examines the efficacy of the currently available pharmaceutical and non-pharmaceutical treatment options. METHODS We conducted a selective literature search in PubMed using the search terms "Raynaud's phenomenon", "Raynaud's syndrome," "vasospasm," "vascular acrosyndrome," and "systemic sclerosis," together with a search of the Cochrane Database of Systematic Reviews up to April 2020. RESULTS Raynaud's phenomenon mainly affects the fingers or toes and is typically triggered by cold or emotional stressors. The most important diagnostic steps are demonstration of a tendency towards digital vasospasm, exclusion of occlusions in the afferent arteries and acral vessels, nail-fold capillaroscopy, and determination of autoantibody status. Tumor screening should be arranged in the presence of B symptoms or first manifestation of RP in old age. The onset of RP in childhood is a rare occurrence and points to a secondary origin. The principal options for treatment are protection against cold and administration of calcium antagonists, which reduces the occurrence of RP by around 20-40 %. The treatment of RP in patients with systemic sclerosis is described in the recommendations of the European League Against Rheumatism (EULAR). CONCLUSION At onset or after years of latency, patients with Raynaud phenomenon may have an underlying disease (most commonly a connective tissue disease). Long-term specialist care is necessary for asymptomatic patients with risk factors and for those with clinically manifest symptoms of an underlying condition alike.
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Affiliation(s)
- Peter Klein-Weigel
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Oliver Sander
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Düsseldorf University Hospital, Faculty of Medicinet, Heinrich Heine University Düsseldorf: Dr. med. Oliver Sander, Prof. Dr. med. Jutta G. Richter
| | - Simone Reinhold
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Jessica Nielitz
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Julia Steindl
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Jutta G. Richter
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Düsseldorf University Hospital, Faculty of Medicinet, Heinrich Heine University Düsseldorf: Dr. med. Oliver Sander, Prof. Dr. med. Jutta G. Richter
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Potluri TK, Lee FG, Song E, Wallace SJ, Miller N. Use of Botulinum Toxin A to Treat Chemotherapy-Induced Raynaud's Phenomenon. Cureus 2021; 13:e12511. [PMID: 33564517 PMCID: PMC7863048 DOI: 10.7759/cureus.12511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Raynaud’s phenomenon (RP) is a vasospastic disorder of the digital blood vessels leading to pain, paresthesias, and pallor in response to cold or stress. RP can develop secondary to a number of pathologies or factors, including the use of chemotherapy agents. Typical first-line therapies for secondary RP may be contraindicated in patients with certain comorbidities. Here, we discuss a case in which botulinum toxin A (BTX-A) was used to treat chemotherapy-induced RP in a patient with non-small cell lung cancer (NSCLC). We provide a review of the existing literature on the clinical course and treatment modalities, including the use of BTX-A, for patients with secondary RP. A 56-year-old female with NSCLC received treatment with bevacizumab and pemetrexed. Her initial symptoms included progressive discoloration and pain in her fingertips, which hastily progressed to ischemia and subsequent dry gangrene. She was diagnosed with chemotherapy-induced RP, but traditional management options were complicated by acute congestive heart failure. BTX-A injections were administered at key locations on the wrist and hand, significantly improving her symptoms and slowing the progression of the gangrenous changes. RP can develop as sequelae of chemotherapy regimens. Clinical management may be complicated by underlying pathology and/or patient symptoms. BTX-A injections are an excellent non-operative therapeutic option for patients with secondary RP in cases where mainstay therapies may be contraindicated, thus decreasing pain, improving patient quality of life, and slowing the progression of gangrenous changes.
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Affiliation(s)
- Thrisha K Potluri
- Department of Plastic Surgery and Reconstructive Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Frank G Lee
- Department of Plastic Surgery and Reconstructive Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Ethan Song
- Department of Plastic Surgery and Reconstructive Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Sean J Wallace
- Division of Plastic & Reconstructive Surgery, Lehigh Valley Health Network, Allentown, USA
| | - Nathan Miller
- Division of Plastic & Reconstructive Surgery, Lehigh Valley Health Network, Allentown, USA
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17
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Gallegos JE, Inglesby DC, Young ZT, Herrera FA. Botulinum Toxin for the Treatment of Intractable Raynaud Phenomenon. J Hand Surg Am 2021; 46:54-59. [PMID: 32948347 DOI: 10.1016/j.jhsa.2020.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/23/2020] [Accepted: 07/18/2020] [Indexed: 02/02/2023]
Abstract
Raynaud phenomenon (RP) is a condition causing vasospasm in the fingers and toes of patients that can have a significant negative impact on quality of life. This can lead to pain, ulceration, and possible loss of digits. Several pharmacological options are available for treatment. However, RP can often be refractory to traditional modalities, leaving surgery or injections as the next available options. This article provides a review and update on the use of botulinum toxin as an effective therapy for the treatment of RP refractory to medical management.
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Affiliation(s)
- Jose E Gallegos
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Dani C Inglesby
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Zachary T Young
- College of Medicine, Medical University of South Carolina, Charleston, SC; Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, SC
| | - Fernando A Herrera
- College of Medicine, Medical University of South Carolina, Charleston, SC; Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, SC; Department of Surgery, Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC.
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18
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Hui-Chou HG, Thakkar MY, Means KR, Higgins JP. A Prospective Pilot Study of Vascular Assessment of the Upper Extremity With Laser Angiography. Hand (N Y) 2020; 15:870-876. [PMID: 30895817 PMCID: PMC7850253 DOI: 10.1177/1558944719837023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Our goal was to investigate patients' upper extremity tissue perfusion changes using an indocyanine green laser angiography imaging system for various pathologic states and interventions. Methods: This prospective observational study used Spy Elite/LUNA laser angiography to evaluate perfusion in patients with upper extremity vascular compromise. All patients had Spy Elite/LUNA imaging as well as clinical and handheld Doppler examinations preintervention, intraoperatively, if applicable, and at 1 week, 2 weeks, and 2 months postintervention. For each laser angiography scan, we used an unaffected control area with uninjured skin to quantitatively compare with the dysvascular tissues. Results: Twelve patients, 7 men and 5 women, had a total of 16 upper extremities evaluated. The mean age was 53 years, and half of the patients entering the study were smokers. Etiologies of vascular compromise were trauma, primary and secondary vasospastic disease, scleroderma, and intravascular drug injection. Interventions included surgical repair/reconstruction, botulinum toxin injections, and/or systemic medications. Improvement in perfusion following intervention was statistically significant, demonstrated by an increase in Spy Elite/LUNA quantitative score postintervention compared with preintervention scans. Adjusting for other variables, such as smoking and handheld Doppler signal status, demonstrated an independent statistically significant increase in Spy Elite/LUNA scores at all postintervention time points compared with preintervention scores. Laser angiography was able to confirm adequate vascular status, with ultimate tissue survival, in some cases when Doppler signals were not initially present. Conclusions: Laser angiography provided objective data to document improved upper extremity tissue perfusion following various interventions.
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Affiliation(s)
- Helen G. Hui-Chou
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Madhuli Y. Thakkar
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Kenneth R. Means
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - James P. Higgins
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA,James P. Higgins, Care of Anne Mattson, The Curtis National Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert Street, JPB #200, Baltimore, MD 21218, USA.
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19
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Quintana Castanedo L, Feito Rodríguez M, Maseda Pedrero R, Chiloeches Fernández C, de Lucas Laguna R. Ischemic ulcers of the toes secondary to Raynaud's phenomenon in a child successfully treated with botulinum toxin. Pediatr Dermatol 2020; 37:681-683. [PMID: 32212180 DOI: 10.1111/pde.14160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Raynaud's phenomenon (RP) is an episodic vasospastic response to cold or emotional stress causing color changes and pain. These attacks can lead to digital ischemia, ulcers, and gangrene. Severe and refractory RP in children is a therapeutic challenge for clinicians because there are no standardized treatment protocols for these patients. We present a case of RP involving the toes of a child successfully treated with botulinum toxin A.
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20
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Is Botulinum Toxin Useful in Systemic Sclerosis Related Peripheral Vasculopathy? A Literature Review. ACTA ACUST UNITED AC 2020; 17:357-363. [PMID: 32591260 DOI: 10.1016/j.reuma.2020.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 03/03/2020] [Accepted: 04/02/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION In systemic sclerosis (SSc), peripheral vasculopathy presents typically as Raynaud Phenomenon (RP) and Digital Ulceration (DU). Over the last decade, botulinum toxin (BT) has been reported effective in this scenario. Our goal was to review existing literature evaluating the efficacy of BT on RP/DU in SSc. MATERIALS AND METHODS We performed a search in Pubmed with the MeSH terms "systemic sclerosis" and "botulinum toxin". Original studies evaluating BT in the treatment of SSc-associated RP/DU were considered for inclusion. Results were screened by title, abstract and full-text. RESULTS We identified 30 results, of which 5 original papers were included: 2 randomized controlled trials (RCT), 2 case series and 1 case control study, from a total of 133 patients. Only one RCT showed negative results, with worse blood flow in treated arm, but with lower dose of BT. Despite this, all 5 included studies reported improvement of at least 1 RP/hand function outcome measure. Concerning DU healing, resolution of baseline DU at the end of follow-up was reported in 75-100% of the patients, with 1 RCT showing superiority over placebo. The only reported adverse effect was transient hand weakness, affecting only 0-16.7% of patients. BT injection protocols were highly heterogeneous. CONCLUSION Despite conflicting results in 1 RCT, evidence points BT as an option in the treatment of SSc-related peripheral vasculopathy. However, future larger prospective trials are necessary to corroborate this hypothesis.
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21
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Abstract
Posttraumatic hand injuries from crush injury, infusion, or iatrogenic vascular cannulation can cause ischemic finger damage that can progress to necrosis and digital amputation. Botulinum toxin type A (Botox) improves blood flow in chronic vasospastic disorders of the hand. Botox's efficacy in salvaging ischemic loss in digits in acute traumatic and iatrogenic injury has not been previously reported. From February of 2015 to December of 2016, 11 patients at a Level I trauma center (West Virginia University) presented to the hand surgery service with early ischemic injury and vascular compromise to hand and fingers as a result of crush, direct drug injection, or proximal arterial injury from drug injection or catheterization. Before 2015, all patients with vascular compromise were treated with standard protocol. After January of 2016, patients were treated with additional injection of 80 to 100 U of Botox into the palm and wrist. Before administration of Botox, six patients with vascular compromise of one or more fingers were treated with a conservative protocol and 83 percent had amputation of necrotic digits. After January of 2016, five patients with ischemia were treated with Botox into the palm and proximal arteries. All Botox-treated digits were preserved (100 percent salvage). Pain scores were lower in Botox-treated fingers. We conclude that (1) in the acute traumatic vascular hand injury, early Botox injection markedly increases digital salvage; (2) direct nerve effects after Botox injections improve postinjury pain scores; and (3) early use of Botox in finger injuries is our standard approach to impending ischemia in the hand.
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22
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Abstract
Raynaud phenomenon is a symptom complex caused by impaired digital perfusion and can occur as a primary phenomenon or secondary to a wide range of underlying causes. Raynaud phenomenon occurs in virtually all patients with systemic sclerosis (SSc) and is often the earliest clinical manifestation to occur. Careful assessment is required in patients with Raynaud phenomenon to avoid missing secondary causes such as SSc. Digital ulcers are a painful and disabling visible manifestation of digital vascular injury in patients with SSc. Progress has been made in the classification and assessment of digital ulcers and in understanding ulcer pathogenesis, and there are a wide range of treatments available to both prevent and heal digital ulcers, some of which are also used in Raynaud phenomenon management. In this Review, the assessment of patients with Raynaud phenomenon is discussed, including 'red flags' that are suggestive of SSc. The pathogenesis, classification and assessment of SSc-associated digital ulcers are also covered, alongside an overview of management approaches for SSc-associated Raynaud phenomenon and digital ulcers. Finally, unmet needs are discussed and the concept of a unified vascular phenotype in which therapies that affect the vasculature to support disease modification strategies is introduced.
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23
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Hu L, Feng Y, Liu W, Jin L, Nie Z. Botulinum toxin type A suppresses arterial vasoconstriction by regulating calcium sensitization and the endothelium-dependent endothelial nitric oxide synthase/soluble guanylyl cyclase/cyclic guanosine monophosphate pathway: An in vitro study. Exp Biol Med (Maywood) 2019; 244:1475-1484. [PMID: 31547684 DOI: 10.1177/1535370219878143] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- Liang Hu
- Department of Neurology, Yangpu Hospital, Tongji University School of Medicine, Shanghai 200090, China
| | - Ya Feng
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Wuchao Liu
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Lingjing Jin
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Zhiyu Nie
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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Dhaliwal K, Griffin MF, Salinas S, Howell K, Denton CP, Butler PEM. Optimisation of botulinum toxin type a treatment for the management of Raynaud's phenomenon using a dorsal approach: a prospective case series. Clin Rheumatol 2019; 38:3669-3676. [PMID: 31482318 DOI: 10.1007/s10067-019-04762-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/09/2019] [Accepted: 08/22/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Raynaud's phenomenon (RP) is a common condition and causes pain, paraesthesia, ulceration and gangrene. Botulinum toxin A (Btx-A) is effective when injected via a digital palmar approach, in the treatment of severe RP. However, hand weakness resulting from lumbrical malfunction is a recognized complication. This study aimed to determine the effect of Btx-A injected via a dorsal approach. METHOD Forty patients received 100 units of Btx-A, injected across both hands via a dorsal approach. Each patient had a baseline, 6- and 12-week hand assessment and thermographic image (FLIR E60bx) performed for the study. RESULTS Eighty-eight percent of patients reported an improvement in symptoms including reduction in pain, improved colour change with reduced swelling and edema at 6 weeks. Of these patients, 80% reported an improvement in cold intolerance with a reduction in the frequency and severity of Raynaud's attacks. There was a significant improvement in both the DASH score (p = 0.001), Kapandji score (p = 0.001) and hand strength (p < 0.05). No patients reported weakness. Improvements in hand function and symptoms of RP were still evident at 12 weeks. CONCLUSIONS Btx-A injected via a dorsal approach improves symptoms and reduces the number of RP. We have shown an effective non-surgical approach technique to treat RP.Key Points• Raynaud's phenomenon is a common vasospastic disorder of the digital vessels, which can cause severe pain, restrictions to hand function and ulceration.• Dorsal botulinum toxin type A injections can improve the symptoms of secondary Raynaud's phenomenon and hand function for approximately 3 months.
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Affiliation(s)
- Kiran Dhaliwal
- Charles Wolfson Center for Reconstructive Surgery, Royal Free Hospital, London, UK.,UCL Centre for Nanotechnology and Regenerative Medicine, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK.,Royal Free Hospital, London, UK.,Plastic & Reconstructive Surgery, Royal Free Hospital, London, UK
| | - Michelle F Griffin
- Charles Wolfson Center for Reconstructive Surgery, Royal Free Hospital, London, UK. .,UCL Centre for Nanotechnology and Regenerative Medicine, London, UK. .,Division of Surgery & Interventional Science, University College London, London, UK. .,Royal Free Hospital, London, UK. .,Plastic & Reconstructive Surgery, Royal Free Hospital, London, UK.
| | - Sebastian Salinas
- Charles Wolfson Center for Reconstructive Surgery, Royal Free Hospital, London, UK.,UCL Centre for Nanotechnology and Regenerative Medicine, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK.,Royal Free Hospital, London, UK.,Plastic & Reconstructive Surgery, Royal Free Hospital, London, UK
| | - Kevin Howell
- Charles Wolfson Center for Reconstructive Surgery, Royal Free Hospital, London, UK.,Royal Free Hospital, London, UK.,Center for Rheumatology, UCL Division of Medicine and Royal Free London NHS Foundation Trust Hospital, London, UK
| | - Christopher P Denton
- Charles Wolfson Center for Reconstructive Surgery, Royal Free Hospital, London, UK.,Royal Free Hospital, London, UK.,Center for Rheumatology, UCL Division of Medicine and Royal Free London NHS Foundation Trust Hospital, London, UK
| | - Peter E M Butler
- Charles Wolfson Center for Reconstructive Surgery, Royal Free Hospital, London, UK.,UCL Centre for Nanotechnology and Regenerative Medicine, London, UK.,Division of Surgery & Interventional Science, University College London, London, UK.,Royal Free Hospital, London, UK.,Plastic & Reconstructive Surgery, Royal Free Hospital, London, UK
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25
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Pauling JD, Hughes M, Pope JE. Raynaud's phenomenon-an update on diagnosis, classification and management. Clin Rheumatol 2019; 38:3317-3330. [PMID: 31420815 DOI: 10.1007/s10067-019-04745-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/01/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
Abstract
Raynaud's phenomenon (RP) is used to describe a symptom complex caused by digital vascular compromise. RP is a clinical diagnosis. The typically episodic nature of RP has resulted in a reliance upon patient self-report for diagnosis. The term 'primary RP' is generally applied when no underlying pathology can be demonstrated. Whilst 'primary RP' is currently considered a distinct disorder, there is evidence that the term may comprise several entities that include a functional vasospastic disorder, a physiologically appropriate thermoregulatory response, subclinical atherosclerosis and 'cold intolerance'. Optimal management may differ depending on cause. The term 'secondary RP' encompasses a broad range of rheumatological, haematological, endocrinological and vascular pathology. RP can range from relatively benign but intrusive vasospasm, to the progressive obliterative microangiopathy of systemic sclerosis (SSc), in which severe digital ischaemia can threaten tissue viability. SSc has formed the focus of much of the research into RP but, consistent with most medical symptom complexes, the aetiopathogenesis of RP varies greatly dependent on cause. Vasospasm within the digital macro- and microvasculature occurs in SSc, but digital ischaemia is further compounded by a progressive obliterative microangiopathy. Recent work exploring the patient experience of SSc-RP is challenging the 'episodic' paradigm of 'Raynaud's', with important implications for clinical trials utilising diary-based patient-reported outcome instruments for assessing Raynaud's symptoms. This review shall examine the causes, pathogenesis, clinical features, classification and management of RP. A practical approach to the evaluation and management of RP is outlined, highlighting important knowledge gaps and unmet research needs where applicable. Key Points • Raynaud's phenomenon is a symptom complex related to digital vascular compromise secondary to broad-ranging pathology. • Raynaud's phenomenon, as currently classified, likely encompasses a number of aetiopathogenic processes. • Raynaud's phenomenon causes significant disease-related morbidity in autoimmune rheumatic diseases such as systemic sclerosis.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Upper Borough Walls, Bath, BA1 1RL, UK.
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.
| | - Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Janet E Pope
- University of Western Ontario, London, ON, Canada
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Tanyeli O, Duman I, Dereli Y, Gormus N, Toy H, Sahin AS. Relaxation matters: comparison of in-vitro vasodilatory role of botulinum toxin-A and papaverine in human radial artery grafts. J Cardiothorac Surg 2019; 14:15. [PMID: 30665449 PMCID: PMC6341691 DOI: 10.1186/s13019-019-0837-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 01/14/2019] [Indexed: 11/26/2022] Open
Abstract
Background Radial artery (RA) is widely used in coronary artery bypass (CABG) surgery and the prevention of spasm is crucial for graft patency. Botulinum toxin A (BTX-A) and B are commonly used for aesthetic reasons and neuromuscular disorders. They are proven to raise blood flow and increase survival of ischemic skin flaps. In this study we evaluated and compared the vasodilator effects of BTX-A and papaverine on human RA grafts. Methods After resting 60 min in isolated organ baths, human RA grafts were examined. Contraction responses for different doses of serotonin (5-HT) and endothelin-1 (ET-1) were evaluated as a percent of maximum contraction response elicited by 80 mM potassium chloride (KCl). The inhibitory effects of BTX-A and papaverine on contraction responses taken at the 0th hour were compared with the 1st and 2nd hour responses. Inhibitory effects of BTX-A and papaverine against the contractile agent were evaluated by comparing the results of the first and last (0th and 2nd hour) application. Results In low concentrations, when we compared the effects of BTX-A (10− 8 M) and papaverine (10− 6 M) on 5-HT, papaverine was found to be more effective at both the 0th and 2nd hour (p < 0.05). Both BTX-A and papaverine inhibited the maximum contractile effect of ET-1 to the same extent at the 0th hour; but, the inhibitory effect of BTX-A was significantly stronger at the 2nd hour (p < 0.05). In high concentrations, when we compared the effects of BTX-A (10− 6 M) and papaverine (10− 4 M) on 5-HT, papaverine showed stronger inhibition (p < 0.05), whereas both agents had similar action of inhibition on ET-1 mediated maximum contraction responses. Conclusion BTX-A inhibits both ET-1 and 5-HT induced contractions and its effectiveness does not decrease over time as observed with papaverine. This study is the first in the literature using human RA for prevention of vasospasm by BTX-A.
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Affiliation(s)
- Omer Tanyeli
- Department of Cardiovascular Surgery, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey.
| | - Ipek Duman
- Department of Pharmacology, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Yuksel Dereli
- Department of Cardiovascular Surgery, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Niyazi Gormus
- Department of Cardiovascular Surgery, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Hatice Toy
- Department of Pathology, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Ayse Saide Sahin
- Department of Pharmacology, Meram Medicine Faculty, Necmettin Erbakan University, Konya, Turkey
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Medina S, Gómez-Zubiaur A, Valdeolivas-Casillas N, Polo-Rodríguez I, Ruíz L, Izquierdo C, Guirado C, Cabrera A, Trasobares L. Botulinum toxin type A in the treatment of Raynaud's phenomenon: A three-year follow-up study. Eur J Rheumatol 2018; 5:224-229. [PMID: 30501848 PMCID: PMC6267752 DOI: 10.5152/eurjrheum.2018.18013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 05/06/2018] [Indexed: 01/18/2023] Open
Abstract
Objective Raynaud’s phenomenon consists of vasospastic disease of the digital arteries after exposure to cold or stress. It causes an important reduction in the patient’s quality of life when severe. The available treatments do not always offer favorable results. Methods A 3-year retrospective study was presented. A total of 15 patients with severe Raynaud’s phenomenon who required infiltration with botulinum toxin type A participated in the study. In the first and follow-up visits (30 min, 7 days, 3 months, 6 months, and annual), the overall response by the patient was assessed as was the reduction in the number of weekly episodes of Raynaud’s phenomenon, improvement in pain by means of the Visual Analogue Scale, and resolution of ulcers and necrosis as efficacy variables. Results A total of 15 patients were included in the study. After 30 min of infiltration, the immediate results showed a very good perception of response in four patients. After 1 month of treatment, eight patients had obtained and maintained a very good response, persisting throughout the study. A statistically significant reduction in pain was obtained, as well as the number of weekly episodes of Raynaud’s phenomenon. Of the seven patients with basal ulcers, five were completely healed at 3 months. Of the patients, 64.3% showed an overall satisfaction level of >8 at the end of treatment. No serious adverse events were observed. Conclusion Botulinum toxin is a useful treatment for severe Raynaud’s phenomenon that is generally well tolerated. Its mechanism of action is not based exclusively on vasodilation. Further studies are necessary to define the ideal patient for this treatment, the most appropriate method of administration, and the number of units and frequency of the infiltrations.
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Affiliation(s)
- Susana Medina
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Alba Gómez-Zubiaur
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | | | - Isabel Polo-Rodríguez
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Lucia Ruíz
- Department of Rheumatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Carmen Izquierdo
- Department of Radiology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Cristina Guirado
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Alicia Cabrera
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Lidia Trasobares
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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Zhou Y, Liu Y, Hao Y, Feng Y, Pan L, Liu W, Li B, Xiao L, Jin L, Nie Z. The mechanism of botulinum A on Raynaud syndrome. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:1905-1915. [PMID: 29983545 PMCID: PMC6027706 DOI: 10.2147/dddt.s161113] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Botulinum neurotoxin type A (BoNT/A) is emerging as a treatment modality for Raynaud's phenomenon (RP). However, the mechanism of the role of BoNT/A in antagonizing the constriction of arteriola in RP remains unclear. Materials and methods We tested the constriction of arteriole diameter and the distribution of adrenergic receptors on the rat cremaster modle. Moreover, we measured the secretion of norepinephrine (NE), protein level changes and related receptors on cultured rat superior cervical ganglia neurons(SCGNs), a model of sympathetic neuron. Results Based on our results, the inhibition of arteriole vasoconstriction was increased with increasing doses of BoNT/A. BoNT/A, prazosin, and BQ123 treatment can result in significant inhibition of arteriole vasoconstriction with the same electrical stimulation. The inhibition effect of prazosin was equivalent to BoNT/A, while BQ123 has a synergistic effect with BoNT/A. After treating SCGNs using BoNT/A for 30 min, the decrease in fluorescence intensity of FM1-43 slowed down which was correlated with the doses of BoNT/A. Furthermore, release of NE in the supernatant was significantly decreased as measured by enzyme-linked immunosorbent assay, 24 h after a high dose of BoNT/A (25 µ/mL). Cleaved-SNAP-25 was detected by Western blotting 24 h following BoNT/A (50 µ/mL) treatment. Moreover, receptor SV2C, GM1, and FGFR3 were detected on sympathetic neurons, similarly to cholinergic neurons. Conclusion Our study showed that BoNT/A could significantly inhibit electrical stimulation-induced arteriole vasoconstriction through the sympathetic pathway. The mechanism was similar to the cholinergic one, in which the vesicle release of sympathetic neurons could be inhibited by cleavage of SNAP-25. The end result was blocked vesicle fusion with the presynaptic membrane after BoNT/A treatment, inhibiting the release of the NE.
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Affiliation(s)
- Yanwen Zhou
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Ying Liu
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Yunhua Hao
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Ya Feng
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Lizhen Pan
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Wuchao Liu
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Bing Li
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Libin Xiao
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Lingjing Jin
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Zhiyu Nie
- Department of Neurology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
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Asano Y, Jinnin M, Kawaguchi Y, Kuwana M, Goto D, Sato S, Takehara K, Hatano M, Fujimoto M, Mugii N, Ihn H. Diagnostic criteria, severity classification and guidelines of systemic sclerosis. J Dermatol 2018; 45:633-691. [PMID: 29687465 DOI: 10.1111/1346-8138.14162] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 11/06/2017] [Indexed: 01/17/2023]
Abstract
Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.
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Affiliation(s)
- Yoshihide Asano
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatoshi Jinnin
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasushi Kawaguchi
- Institute of Rheumatology, Tokyo Woman's Medical University, Tokyo, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Daisuke Goto
- Department of Rheumatology, Faculty of Medicine, Univertity of Tsukuba, Ibaraki, Japan
| | - Shinichi Sato
- Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Takehara
- Department of Molecular Pathology of Skin, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Ishikawa, Japan
| | - Masaru Hatano
- Graduate School of Medicine Department of Therapeutic Strategy for Heart Failure, The University of Tokyo, Tokyo, Japan
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoki Mugii
- Section of Rehabilitation, Kanazawa University Hospital, Ishikawa, Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
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Norheim AJ, Mercer J, Musial F, de Weerd L. A new treatment for frostbite sequelae; Botulinum toxin. Int J Circumpolar Health 2018; 76:1273677. [PMID: 28452678 PMCID: PMC5328352 DOI: 10.1080/22423982.2016.1273677] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Frostbite sequelae are a relevant occupational injury outcome for soldiers in arctic environments. A Caucasian male soldier suffered frostbite to both hands during a military winter exercise. He developed sensory-motor disturbances and cold hypersensitivity. Angiography and thermography revealed impaired blood flow while Quantitative Sensory Testing indicated impaired somato-sensory nerve function. Two years after the initial event, he received an off label treatment with Botulinum toxin distributed around the neurovascular bundles of each finger. After treatment, cold sensitivity was reduced while blood flow and somato-sensory nerve function improved. The successful treatment enabled the soldier to successfully pursue his career in the army.
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Affiliation(s)
- Arne Johan Norheim
- a The National Research Centre in Complementary and Alternative Medicine, NAFKAM, Department of Community Medicine, Faculty of Health Sciences , University of Tromsø - The Arctic University of Norway , Norway.,b Institute of Military Epidemiology, Defense Medical Center , Norwegian Armed Forces , Sessvollmoen , Norway
| | - James Mercer
- c Medical Imaging Group, Institute for Clinical Medicine , UiT The Arctic University of Norway , Tromsø , Norway.,d Department of Medical Physiology, Faculty of Medicine , University of Tromsø - The Arctic University of Norway , Norway.,e Department of Radiology , University Hospital North Norway, Tromsø , Norway
| | - Frauke Musial
- a The National Research Centre in Complementary and Alternative Medicine, NAFKAM, Department of Community Medicine, Faculty of Health Sciences , University of Tromsø - The Arctic University of Norway , Norway
| | - Louis de Weerd
- e Department of Radiology , University Hospital North Norway, Tromsø , Norway.,f Department of Plastic Surgery and Hand Surgery , University Hospital North Norway , Tromsø , Norway
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Garrido-Ríos AA, González-Olivares M, Navarro-Vidal B, Martínez-Morán C, Borbujo J. Ischaemic ulcers on the toes secondary to Raynaud phenomenon in a patient with systemic sclerosis successfully treated with botulinum toxin. Clin Exp Dermatol 2017; 43:503-505. [DOI: 10.1111/ced.13333] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2017] [Indexed: 11/28/2022]
Affiliation(s)
- A. A. Garrido-Ríos
- Department of Dermatology; Hospital Universitario de Fuenlabrada; Madrid Spain
| | | | - B. Navarro-Vidal
- Department of Dermatology; Hospital Universitario de Fuenlabrada; Madrid Spain
| | - C. Martínez-Morán
- Department of Dermatology; Hospital Universitario de Fuenlabrada; Madrid Spain
| | - J. Borbujo
- Department of Dermatology; Hospital Universitario de Fuenlabrada; Madrid Spain
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Motegi SI, Sekiguchi A, Saito S, Ishibuchi H, Kishi C, Yasuda M, Ishikawa O. Successful treatment of Raynaud's phenomenon and digital ulcers in systemic sclerosis patients with botulinum toxin B injection: Assessment of peripheral vascular disorder by angiography and dermoscopic image of nail fold capillary. J Dermatol 2017; 45:349-352. [PMID: 29164658 DOI: 10.1111/1346-8138.14140] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/20/2017] [Indexed: 11/28/2022]
Abstract
We recently identified the efficacy and safety of a botulinum toxin (BTX)-A/B in Raynaud's phenomenon (RP) and digital ulcers (DU) in Japanese patients with systemic sclerosis (SSc). Detailed assessments of peripheral vascular disorder using angiography and dermoscopic images of nail fold capillaries have not been performed previously. This study aimed to evaluate the effect of BTX-B on SSc-associated peripheral vascular disorder. Two SSc patients who suffered with RP and DU were treated with a BTX-B injection, and thereafter the symptoms of RP were improved and DU healed in both patients. Furthermore, angiography showed an increased blood flow to the palm and fingers, and dermoscopic images of nail fold capillary changes showed improvement. These results suggest that a BTX-B injection may increase peripheral blood flow and improve RP and DU in SSc patients.
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Affiliation(s)
- Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akiko Sekiguchi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Shintaro Saito
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hirohisa Ishibuchi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Chikako Kishi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Masahito Yasuda
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Osamu Ishikawa
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
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Abstract
Raynaud phenomenon (RP) is a transient digital ischemia that occurs after exposure to cold temperature or emotional distress. It presents with a triphasic course: the initial white phase is followed by cyanotic discoloration and, subsequently, erythema. The attacks may be associated with pain, paresthesia, and complicate with nonhealing ulceration often leading to amputation. To date, there are no clear-cut therapeutic guidelines and many medications are used off-label. Encouraging results were reported with the use of botulinum neurotoxin-A (BoNT-A). However, there is still ongoing debate regarding indications, contraindications, best injection technique, and mechanism of action. The aim of this study was to address these issues by providing an up-to-date and detailed overview of the use of BoNT-A in RP.A PubMed database search was conducted. The available studies and techniques were evaluated and compared.The search yielded a total of 29 studies. Ten papers, published between 2004 and 2014, were considered relevant. A total of 128 patients underwent BoNT-A injections. Seventy-five percent to 100 % of the patients reported pain reduction after treatment. Healing of ulcers was reported in 75% to 100% of the affected patients. The most common complication was temporary hand weakness, with an average incidence of 14.1%. Injections targeting the neurovascular bundle at or slightly proximal to the A1 pulley were the most commonly performed.Botulinum neurotoxin-A injection proved to be a valid approach in both primary and secondary RP. The available evidence shows the achievement of both symptomatic and functional improvements in this debilitating condition. However, the patient should be adequately informed about the risk of transient hand weakness.
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Bello RJ, Cooney CM, Melamed E, Follmar K, Yenokyan G, Leatherman G, Shah AA, Wigley FM, Hummers LK, Lifchez SD. The Therapeutic Efficacy of Botulinum Toxin in Treating Scleroderma-Associated Raynaud's Phenomenon: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Arthritis Rheumatol 2017; 69:1661-1669. [PMID: 28426903 DOI: 10.1002/art.40123] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 04/06/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the therapeutic efficacy of local injections of botulinum toxin type A (Btx-A) in improving blood flow to the hands of patients with Raynaud's phenomenon (RP) secondary to scleroderma. METHODS In this randomized, double-blind, placebo-controlled clinical trial, patients with scleroderma-associated RP received Btx-A (50 units in 2.5 ml sterile saline) in one randomly selected hand and sterile saline (2.5 ml) in the opposite hand. Follow-up at 1 and 4 months postinjection included laser Doppler imaging of hands, patient-reported outcomes, and physical examination. We compared outcomes using paired t-tests and population-average generalized models with generalized estimating equations. RESULTS Of 40 patients enrolled, 25 had limited scleroderma and 15 had diffuse scleroderma. From baseline to 1-month follow-up, there was a greater reduction in average blood flow in Btx-A-treated hands compared to placebo-treated hands. The model estimated that this difference was statistically significant (average difference -30.08 flux units [95% confidence interval -56.19, -3.98], P for interaction = 0.024). This difference was mainly influenced by patients with longstanding RP and diffuse scleroderma. Change in blood flow at 4-month follow-up was not significantly different between groups. Clinical measures (QuickDASH, McCabe Cold Sensitivity Score, pain on a visual analog scale, and Raynaud's Condition Score) improved slightly for Btx-A-treated hands. CONCLUSION Our laboratory-based laser Doppler imaging flow data do not support using Btx-A to treat RP in all scleroderma patients. The secondary clinical outcomes suggest some positive effect, but its clinical meaningfulness is questionable. The role of Btx-A in treating RP should be further studied with more homogeneous patient populations and in unique clinical situations such as acute digital ischemia.
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Affiliation(s)
| | | | | | | | | | | | - Ami A Shah
- Johns Hopkins University, Baltimore, Maryland
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Abstract
INTRODUCTION Raynaud's phenomenon (RP) can be either primary (idiopathic) or secondary to a number of different diseases/conditions, when vasopasm can be superimposed upon structural vascular abnormality or a hyperviscosity state and may then lead to severe ischaemia with tissue damage. Treatment must be tailored to the individual. Areas covered: This review discusses how increased understanding of the pathogenesis of RP has driven and is driving new approaches to therapy, and how we are now better able to predict which patients presenting with RP are likely to have an underlying disease requiring specific intervention. Medline searches (1946 to August 2016) were conducted for 'Raynaud's' in combination with relevant terms including different drugs. All papers identified were English language, with abstracts. Expert commentary: Randomised controlled trials of RP present particular challenges. The major aim must continue to be development of safe, effective treatments for patients across the spectrum of RP.
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Affiliation(s)
- Ariane L Herrick
- a Division of Musculoskeletal and Dermatological Sciences , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK.,b NIHR Manchester Musculoskeletal Biomedical Research Unit , Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK
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Differential diagnosis of critical digital ischemia in systemic sclerosis: Report of five cases and review of the literature. Semin Arthritis Rheum 2016; 46:209-216. [DOI: 10.1016/j.semarthrit.2016.05.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/11/2016] [Accepted: 05/09/2016] [Indexed: 12/20/2022]
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Iatrogenic Thenar Eminence Atrophy After Botox A Injection for Secondary Raynaud Phenomenon. J Clin Rheumatol 2016; 22:396-7. [DOI: 10.1097/rhu.0000000000000450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Digital Sympathectomy in Patients With Scleroderma: An Overview of the Practice and Referral Patterns and Perceptions of Rheumatologists. Ann Plast Surg 2016; 75:637-43. [PMID: 26418780 DOI: 10.1097/sap.0000000000000614] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE Periarterial sympathectomy is a treatment option for patients with systemic sclerosis (SSc) suffering from digital vasculopathy. Despite potential benefits of ulcer healing, pain improvement, and amputation prevention, this operation appears to be infrequently performed. The aims of our study are as follows: (1) to assess national digital sympathectomy rates in patients with SSc and (2) to improve our understanding of referring physicians' perceptions of operative management and access to hand surgeons. Our hypothesis is that rheumatologists' practices largely influence their referral patterns for digital sympathectomy. METHODS To determine the rates and demographics of hospitalized patients with SSc who had undergone digital sympathectomy, we queried the Nationwide Inpatient Sample from 2006 to 2010. Additionally, we mailed a self-administered survey to a national sample of 500 board-certified rheumatologists to elicit their practice patterns and perceptions of digital sympathectomy. Using logistic regression, we analyzed potential predictor variables associated with rheumatologists performing the following: (1) routinely counseling patients about digital sympathectomy and (2) expressing the desire to refer these patients for operative evaluation. RESULTS Of 348,539 hospitalizations associated with a diagnosis of SSc, only 0.2% were for digital sympathectomy. Our questionnaire revealed that only 50% of rheumatologists routinely counseled, whereas 67% expressed the desire to refer. Factors associated with increased rheumatologists' interest in surgical management for patients with SSc included positive perception of the operation's efficacy, comfort with postoperative management, and interdisciplinary relationship with a hand surgeon. DISCUSSION Critical components to increasing appropriate utilization of digital sympathectomy include enhancing rheumatologists' understanding of the operation, comfort with postoperative management, and promoting strong, interdisciplinary relationships with hand surgeons. Increasing education and awareness, as well as establishing a solid referral network of hand surgeons may thereby improve patient access to digital sympathectomy.
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Żebryk P, Puszczewicz MJ. Botulinum toxin A in the treatment of Raynaud's phenomenon: a systematic review. Arch Med Sci 2016; 12:864-70. [PMID: 27478469 PMCID: PMC4947604 DOI: 10.5114/aoms.2015.48152] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 08/13/2014] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION The management of Raynaud's phenomenon in its most severe form is challenging, and current medical and surgical treatment methods frequently do not lead to optimal symptom control and prevention of ischemic complications. The aim of the study was to critically evaluate all existing evidence on the use of botulinum toxin A in the management of Raynaud's phenomenon. MATERIAL AND METHODS We adopted the PRISMA methodology and searched Cochrane Library, MEDLINE, SCOPUS, EULAR and ACR congresses abstract archives for Raynaud* AND botulinum toxin OR onabotulinum. All studies that contained reports of botulinum toxin A use and its outcome in Raynaud's phenomenon were included in the review. RESULTS Eleven studies met our inclusion criteria and involved a total of 125 patients. Two reviewers extracted data from the studies under review and achieved a consensus in their selection. The main outcomes measured were pain reduction and healing of digital ulcers. The level of evidence across studies was very low to moderate. CONCLUSIONS There is insufficient evidence to assess the efficacy of botulinum toxin A in Raynaud's phenomenon. Despite many promising reports, further research in the form of randomized controlled trials is warranted in order to investigate this new treatment method for Raynaud's phenomenon.
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Affiliation(s)
- Paweł Żebryk
- Department of Rheumatology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Mariusz J Puszczewicz
- Department of Rheumatology and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
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Forbat E, Ali F, Al-Niaimi F. Non-cosmetic dermatological uses of botulinum neurotoxin. J Eur Acad Dermatol Venereol 2016; 30:2023-2029. [DOI: 10.1111/jdv.13772] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 04/19/2016] [Indexed: 12/29/2022]
Affiliation(s)
| | - F.R. Ali
- Dermatological Surgery & Laser Unit; St John's Institute of Dermatology; St Thomas' Hospital; London UK
| | - F. Al-Niaimi
- Dermatological Surgery & Laser Unit; St John's Institute of Dermatology; St Thomas' Hospital; London UK
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Abstract
Raynaud's phenomenon (RP) is a major cause of pain and disability in patients with autoimmune connective tissue diseases (CTDs), particularly systemic sclerosis (SSc). The clinician must perform a comprehensive clinical assessment in patients with RP to differentiate between primary (idiopathic) and secondary RP, in particular (for rheumatologists), secondary to an autoimmune CTD, as both the prognosis and treatment may differ significantly. Key investigations are nailfold capillaroscopy and testing for autoantibodies (in particular, those associated with SSc). Patients with RP and either abnormal nailfold capillaroscopy or an SSc-specific antibody (and especially with both) have a high risk of transitioning to an autoimmune CTD. Both nailfold capillaroscopy and autoantibody specificity may help the clinician in predicting organ-based complications. The management of CTD-associated RP requires a multifaceted approach to treatment, including patient education and conservative ('non-drug') measures. Patients with CTD-associated RP often require pharmacological treatment, which in the first instance is usually a calcium channel blocker, although other agents can be used. There is an increasing tendency to use phosphodiesterase type 5 inhibitors early in the treatment of CTD-associated RP. Oral therapies are commonly associated with side effects (often due to systemic vasodilation) that may result in failure of dose escalation and/or permanent discontinuation. Intravenous prostanoid therapy and surgery (e.g., botulinum toxin injection and digital sympathectomy) can be considered in severe RP. Patients with CTD-associated RP can develop a number of ischaemic digital complications (primarily ulcers and critical ischaemia), which may be associated with significant tissue loss. Future research is required to increase the understanding of the pathogenesis and natural history of RP (to drive therapeutic advances), and to explore/develop drug therapies, including those that target the mechanisms mediating cold-induced vasoconstriction, and locally acting therapies free of systemic side effects.
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Affiliation(s)
- Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
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Navarro EP, Cañas CA, Tobón GJ. Management of Raynaud’s digital ulcer with interdigital Botulinum toxin A injection. Rheumatology (Oxford) 2016; 55:1216. [DOI: 10.1093/rheumatology/kew225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Hughes M, Herrick AL. Digital ulcers in systemic sclerosis. Rheumatology (Oxford) 2016; 56:14-25. [PMID: 27094599 DOI: 10.1093/rheumatology/kew047] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/15/2016] [Indexed: 11/14/2022] Open
Abstract
Digital ulcers (DUs) are a common visible manifestation of the progressive vascular disease that characterizes the SSc disease process. DUs not only impact significantly on patients' quality of life and hand function, but are also a biomarker of internal organ involvement and of disease severity. The aetiology of (digital) vascular disease in SSc is multifactorial, and many of these factors are potentially amenable to therapeutic intervention. The management of DU disease in SSc is multifaceted. Patient education and non-pharmacological interventions (e.g. smoking cessation) should not be neglected. There are a number of drug therapies available to prevent (e.g. phosphodiesterase type-5 inhibitors and ET receptor-1 antagonists) and treat (e.g. i.v. iloprost) DUs. DUs are also important for two other reasons: firstly, as a primary end point in SSc-related clinical trials; and secondly, DUs are included in the ACR/EULAR SSc classification criteria. However, the reliability of rheumatologists to grade DUs is poor to moderate at best, and this poses challenges in both clinical practice and research. The purpose of this review is to provide the reader with a description of the spectrum of DU disease in SSc including pathophysiology, epidemiology and clinical burden, all of which inform the multifaceted approach to management.
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Affiliation(s)
- Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Gunnarsson R, Hetlevik SO, Lilleby V, Molberg Ø. Mixed connective tissue disease. Best Pract Res Clin Rheumatol 2016; 30:95-111. [DOI: 10.1016/j.berh.2016.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Camargo CP, Jacomo AL, Battlehner CN, Lemos M, Saldiva PH, Martins MA, Munhoz AM, Gemperli R. Botulinum toxin type A on cutaneous flap viability in diabetic and tobacco-exposed rats. Acta Cir Bras 2015; 30:639-45. [DOI: 10.1590/s0102-865020150090000009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 08/17/2015] [Indexed: 11/22/2022] Open
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46
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Motegi SI, Yamada K, Toki S, Uchiyama A, Kubota Y, Nakamura T, Ishikawa O. Beneficial effect of botulinum toxin A on Raynaud's phenomenon in Japanese patients with systemic sclerosis: A prospective, case series study. J Dermatol 2015; 43:56-62. [DOI: 10.1111/1346-8138.13030] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 06/11/2015] [Indexed: 12/16/2022]
Affiliation(s)
- Sei-ichiro Motegi
- Department of Dermatology; Gunma University Graduate School of Medicine; Maebashi Japan
| | - Kazuya Yamada
- Department of Dermatology; Gunma University Graduate School of Medicine; Maebashi Japan
| | - Sayaka Toki
- Department of Dermatology; Gunma University Graduate School of Medicine; Maebashi Japan
| | - Akihiko Uchiyama
- Department of Dermatology; Gunma University Graduate School of Medicine; Maebashi Japan
| | - Yuka Kubota
- Clinical Investigation and Research Unit; Gunma University Graduate School of Medicine; Maebashi Japan
| | - Tetsuya Nakamura
- Clinical Investigation and Research Unit; Gunma University Graduate School of Medicine; Maebashi Japan
| | - Osamu Ishikawa
- Department of Dermatology; Gunma University Graduate School of Medicine; Maebashi Japan
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Abstract
Raynaud’s phenomenon and digital ulcerations are two common clinical features seen in patients with systemic sclerosis. They are painful and lead to significant morbidity and altered hand function within this patient population. While currently there are no US Food and Drug Administration (FDA)-approved medications for the treatment of digital ulcerations in the United States, clinical trials have supported the use of pharmacologic and nonpharmacologic modalities in facilitating healing of existing digital ulcers and preventing formation of new ulcers. This article reviews the published data on these therapeutic options.
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Affiliation(s)
- Shawn Abraham
- Division of Rheumatology, immunology, and Allergy, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Virginia Steen
- Division of Rheumatology, immunology, and Allergy, MedStar Georgetown University Hospital, Washington, DC, USA
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48
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Zhao H, Lian Y. Clinical and image improvement of Raynaud's phenomenon after botulinum toxin type A treatment. Australas J Dermatol 2015; 56:202-5. [PMID: 25817568 DOI: 10.1111/ajd.12326] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 02/11/2015] [Indexed: 11/29/2022]
Affiliation(s)
- HongMei Zhao
- Department of Neurology; First Affiliated Hospital of Zhengzhou University; Zhengzhou Henan China
| | - YaJun Lian
- Department of Neurology; First Affiliated Hospital of Zhengzhou University; Zhengzhou Henan China
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50
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Abstract
Hypothenar hammer syndrome is a rare vascular condition resulting from injury to the ulnar artery at the level of Guyon canal. The ulnar artery at the wrist is the most common site of arterial aneurysms of the upper extremity and is particularly prone to injury. Signs and symptoms include a palpable mass, distal digital embolization to long, ring, or small fingers, pain, cyanosis, pallor, coolness, and recurrent episodes of vasospasm. Modalities for diagnosis, evaluation, and surgical planning include duplex study, contrast arteriography, and computerized tomographic angiography (CTA). Management includes medical, nonoperative, or operative treatments. Appropriate treatment options are reviewed.
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