A series of 11 patients with severe vasospasm, intractable rest pain, digital ulcerations, and digit infarctions treated with Botulinum Toxin A (Botox) are presented. All of these patients had connective tissue disorders and had failed conventional multi-drug therapy including oral and parenteral agents. Each symptomatic hand was injected with a total of 100 units of Botox distributed over 8-10 injection sites that targeted the superficial palmar arch, common digital arteries, and proper digital arteries (8- 12 units per site).
The average follow-up was 9.6 month and the longest follow-up was 30 months. All patients reported relief of rest pain from 9-10 to 0-2 out of 10 within 24-48 hrs after injection. Nine of eleven patients reported decreased episodes of vasospasm and cyanosis. Patients with small digital ulcerations saw spontaneous healing and those with larger infracted areas required debridement and skin grafting. Patients reported that their digits felt subjectively warmer and surface temperature recordings increased by 1-4oC post injection. Three of the eleven patients reported “mild weakness” in their hand but had improved overall function because of decreased pain. In patients with longer follow-up times, repeat injections were required within 3-8 months.
The authors conclude that hand injections with Botox appears to be an effective treatment for intractable digital ulcerations and rest-pain in patients with severe vasospastic disorders and may represent an alternative to surgical sympathectomy. A prospective, randomized, controlled study with statistical analysis and validated outcome questionnaires is certainly needed. Areas of future investigation should include: quantitative measurements of pre- and postoperative blood-flow, controlled recording environment skin temperature measurements, determination of the optimum location, dosage, and timing of Botox injections.
Digital, Ischemia, Ulcerations, Botox, Botulinum, Vasospasm
Plast Reconstr Surg