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Show Journal of Neuro- Ophllwlmology 19( 1): 7- 9, 1999. © 1999 Lippincoll Williams & Wilkins, Inc., Philadelphia Prevalence of Periocular Depigmentation After Repeated Botulinum Toxin A Injections in African American Patients Pamela C. Roehm, Ph. D., Julian D. Perry, M. D., Christopher A. Girkin, M. D., and Neil R. Miller, M. D. Botulinum toxin A ( Botox), administered by subcutaneous or intramuscular injection, is the most commonly used and most successful medication for many craniocervical dystonias. Although some patients experience side effects related to the neuroparalytic action of the medication, these side effects are temporary. In 1996, permanent periocular cutaneous depigmentation was reported in three white patients after repeated Botox injections, suggesting that loss or alteration of melanin pigment might be a permanent side effect of long- term Botox injections. The authors examined and photographed 26 African American patients who were receiving periocular Botox injections for hemifacial spasm and essential blepharospasm. The authors found no evidence of periocular cutaneous depigmentation in any of these patients. Key Words: African American- Botulinum toxin A- Botox- Essential blepharospasm- Hemifacial spasm- Periocular depigmentation- Melanin. Subcutaneous or intramuscular injections of Botulinum toxin A ( Botox) are an effective treatment for several craniocervical dystonias, including blepharospasm, hemifacial spasm, and torticollis ( 1). Commonly reported side effects include ptosis, lagophthalmos, diplopia, facial numbness, and ectropion. Occasionally, pruritus, dysphagia, and generalized malaise and weakness are observed ( 2). In 1996, Friedland and Burde described three patients who developed periocular skin lightening and lower eyelid edema after repeated botox injections for the treatment of benign essential blepharospasm and hemifacial spasm ( 3). Based on the presumption that depigmentation may be easier to detect in heavily pigmented individuals, we examined and photographed 26 African American patients who were receiving Botox injections for essential blepharospasm and hemifacial spasm. Manuscript received June 25, 1998; accepted August 19, 1998. From the Neuro- Oplhalmology Unit, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Address correspondence and reprint requests to Neil R. Miller, M. D., Maumenee B- 109, The Johns Hopkins Hospital, Baltimore, MD 21287 MATERIALS AND METHODS Since 1983, we have treated 548 patients with Botox, 308 patients ( 56.2%) for essential blepharospasm, and 240 patients ( 43.8%) for hemifacial spasm. Of these, 26 patients, 19 with essential blepharospasm and 7 with hemifacial spasm, are African American. All patients have received subcutaneous or intramuscular injections in the pretarsal regions of the upper and lower eyelids, the lateral canthal region, and the brow region on one or both sides, depending on whether they have essential blepharospasm or hemifacial spasm. During regularly scheduled follow- up visits, we examined these 26 patients for evidence of periocular depigmentation and obtained external photographs to document their appearance. RESULTS Patients ranged in age from 19 to 83 years ( mean age, 65.2 years). The number of injections ranged from 1 to 49 ( mean, 13.2), and the total dose ranged from 21.25 to 3,465 units ( mean, 735.9). The mean follow- up time was 7.7 years ( range, 4 months- 14 years). External examination showed no areas of periocular depigmentation nor any persistent eyelid or periorbital edema in any of the patients. Review of photographs of these patients also failed to demonstrate periocular depigmentation or lower eyelid edema in any patient ( Fig. 1). DISCUSSION Subcutaneous Botox injections are the most common and effective method of treating essential blepharospasm, and they are also commonly used to treat hemifacial spasm, with a success rate of nearly 90% ( 4,5). Side effects of the injections are rare and mainly related to the neuroparalytic action of the medication. These side effects, which include ptosis, lagophthalmos, diplopia, facial numbness, and ectropion, are temporary. However, Friedland and Burde described permanent periocular depigmentation associated with lower eyelid edema in three white patients after multiple Botox injections. Their 8 P. C. ROEHM ET AL. ±'' J*^ .-£_<•• .'. ^ * ^ » J ^ « l- -. " • FIG. 1. A- F: External photographs of six African American patients who have received repeated Botulinum toxin A ( Botox) injections for essential blepharospasm or hemifacial spasm. Note the absence of periocular cutaneous depigmentation and eyelid edema. A: A 50- year- old woman with right hemifacial spasm for which she has received a total dose of 550 units of Botox in 25 injections over 8 years. B: A 74- year- old woman with right hemifacial spasm for which she has received a total dose of 100 units of Botox in five injections over 18 months. C: A 83- year- old woman with essential blepharospasm for which she has received a total dose of 1,400 units of Botox in 17 injections over 10 years. D: A 78- year- old man with essential blepharospasm for which he has received a total dose of 1,640 units of Botox in 19 injections over 10 years. E: A 63- year- old woman with essential blepharospasm and Meige syndrome for which she has received a total dose of 2,150 units of Botox in 31 injections over 8 years. F: A 53- year- old woman with right hemifacial spasm for which she has received a total dose of 225 units of Botox in 10 injections over 3 Vfc years. patients received 160 to 350 units of Botox in two to six injections over an unspecified period of time ( 3). We hypothesized that depigmentation might be more pronounced in heavily pigmented skin; however, we found no evidence of such skin changes in any of our 26 African American patients who had received a mean amount of Botox of 735.9 units over a mean period of 7.7 years. In addition, none of the 26 patients examined in this study had eyelid or periorbital edema. The results of this study indicate that depigmentation and lower eyelid edema are uncommon occurrences in African American patients who undergo repeated subcu- ./ Ncum- Ophlhalmol, Vol. 19. No. I. 1999 PREVALENCE OF DEPIGMENTATION AFTER BOTOX 9 taneous or intramuscular injections of Botox. Although the amount as well as the type of melanin ( eumelanin or pheomelanin) may differ among racial groups ( 6,7), we did not observe any changes in periocular appearance after Botox injections in any patient in our large referral-based practice. We believe that Botox is a safe and effective treatment for essential blepharospasm and hemifacial spasm and that the risk of periocular skin changes after repeated injection is negligible, at least in darkly pigmented individuals. REFERENCES 1. Tsui JK. Botulinum toxin as a therapeutic agent. Pharmacol Ther 1996; 72: 13- 24. 2. Dutton JJ. Botulinum- A toxin in the treatment of craniocervical muscle spasms: short- and long- term, local and systemic effects. Surv Ophthalmol 1996; 41: 51- 65. 3. Friedland S, Burde RM. Porcelinizing discoloration of the periocular skin following botulinum A toxin injections. ./ Neurooph-thalmol 1996; 16: 70- 1. 4. Mauriello JA, Dhillon S, Leone T, Pakeman B, Moslafavi R, Ye-pez MC. Treatment selections of 239 patients with blepharospasm and Meige syndrome over 11 years. Br J Ophthalmol 1996; 80: 1073- 6. 5. Mauriello JA, Leone T, Dhillon S, Pakeman B, Moslafavi R, Yc-pez MC. Treatment choices of 119 patients with hemifacial spasm over 11 years. Clin Neurol Neurosurg 1996; 98: 213- 6. 6. Thody AJ, Higgins EM, Wakamatsu K, lto S, Btirchill SA, Marks JM. Pheomelanin as well as eumelanin is present in human epidermis. ./ Invest Dermatol 1991; 97: 340- 4. 7. Valvcrde P, Healy E, Jackson I, Rces JL, Thody AJ. Variants of the melanocytc- stimulating hormone receptor gene arc associated with red hair and fair skin in humans. Nat Genet 1995; I 1: 328- 30. J Neuro- Ophtlmlmol. Vol. 19, No. I. /< W |
