Speaker: Hans-Joachim Laubach
Botulinum toxin (BTX) and laser light therapy were investigated as complementary treatments for various skin conditions. A study conducted utilized fractional lasers or other laser types to treat patients receiving botulinum toxin injections. The study focused on the side effects and efficacy of the treatments across different facial areas. The combination therapy of botulinum toxin and lasers/ energy-based devices may have complimentary actions. The injection of botulinum toxin, a muscle relaxant employed to alter facial anatomy. Although certain areas did not yield optimal results, visible improvements were noted shortly after treatment, typically within a few days and without significant downtime. This is a significant treatment in the dermatologist’s armamentarium. Conversely, laser and energy-based devices were found to stimulate and repair the skin, also evens the skin tone. These devices could be applied to virtually any skin area, although clinical responses varied by location, suggesting potential synergistic effects between the two treatment modalities. Some treatments exhibited better efficacy in specific areas, while others did not. Results were often achieved over the medium to long term, with satisfactory outcomes persisting for years when patients maintained a regimen for their skin concerns.
The initial publication on toxin injection for cosmetic purposes appeared in 1999 and focused on 40 patients who underwent full-phase Carbon Dioxide (CO2) laser resurfacing. The aggressive approach was found to have beneficial effects on wound healing. Following this, patients were randomised to receive botulinum toxin injections in the glabella, forehead, and crow's feet one to three months after laser treatment. The results demonstrated enhanced and more prolonged correction in patients who received both laser treatment and BTX injection, with a follow-up period of nine months. The contraction of glabellar lines began early after treatment, and two Botox injections within a few months exhibited established efficacy. However, injecting toxin in conjunction with laser resurfacing produced superior outcomes compared to resurfacing alone. Over 20 years later, a split-phase study in 2001 reaffirmed that the combination of toxin and resurfacing yielded better results than resurfacing alone. Despite this, the majority of practitioners continued to perform resurfacing procedures concurrently with toxin injections. A controlled split face study conducted in 2004 involved 33 subjects with bilateral symmetrical periorbital rhytids treated with toxins and a placebo. The patients underwent resurfacing with Erb:YAG 2 to 6 weeks post injection. The findings indicated that the efficacy of the toxin was significantly improved when used in conjunction with resurfacing, with the maximum benefit of the muscle relaxant observed two to six weeks post-injection. Overall, the combined use of toxin and resurfacing was effective.
The use of toxins in skin treatments has been a topic of interest for many years. Evidence indicated that these treatments worked well when combined with resurfacing procedures, which were considered safe. However, concerns persisted regarding the safety of using toxins alone or in conjunction with other methods, such as intense pulsed light (IPL) or fractional therapies. A study by David Ozog 2015 demonstrated that employing toxins in the same session as laser therapy, particularly in a fractionated pattern, yielded better results in reducing wrinkles. The conclusion was supported by a split-phase study in which one side of the face was treated with a fractional ablative CO2 laser, followed by either topical saline as a control or topical BTX. The results indicated that the combined treatment produced greater improvements in wrinkle appearance. Additionally, laser-assisted drug delivery with BTX was shown to enhance wound healing. However, it was crucial to consider whether this combination provided better clinical outcomes regarding efficacy and side effects. In A small trial on patients with syringoma,, multiple sessions of Er: YAG were performed and later botulinum toxin was sprayed on the treated area. It was found that applying BTX around the treatment area reduced hyperpigmentation. The finding held significance for clinical practice, suggesting that toxins might influence the inflammatory response in the skin. Combining these treatments demonstrated potential for improving skin tone and reducing hyperpigmentation.
Another study led by Leonard Marini revealed that toxins could modulate the inflammatory response in the skin, particularly in cases of hypertrophic keloid scars. Their effectiveness appeared to stem from releasing muscle tension in areas of increased stress and modulating the skin's inflammatory response.
Hypertrophic scars after any accident in the mentalis region is a common issue associated with specific skin types due to genetic predisposition and the movement of the mentalis muscle. To achieve improved outcomes, it was recommended to relax the mentalis muscle and infiltrate the scar with small doses of botulinum toxin. Caution was advised in the area around the labia inferiors, as this could lead to hypertrophic scarring.
BTX was also utilized in combination therapies for rosacea, a dermatological condition. Pulsed dye and vascular lasers have been employed for decades to treat rosacea by downregulating the inflammatory response and reducing substance P. However, vasoactive intestinal peptide and calcitonin gene-related peptide remained unaffected. A study indicated that BTX addressed problematic cytokines that were not targeted by pulsed dye laser treatment. A synergistic approach involved utilizing BTX for aspects that pulsed dye lasers did not treat. A pivotal study published in 2008 examined the effectiveness of intense pulsed light (IPL) for treating rosacea, where 93% of patients responded positively to the combined treatment of BTX and IPL, in contrast to only 29% who responded to IPL alone. The study included a follow-up by Firas Alnilam from London, who conducted three combination treatments at four to six-week intervals, injecting BTX simultaneously with pulsed dye laser therapy and employing a specific setting. Results revealed no unexpected side effects and demonstrated lasting improvements over three and nine months. However, the author raised questions about the rationale for injecting BTX every four weeks, suggesting that there may be a specific ratio involved. The comparison of pulsed dye lasers with BTX alone prompted inquiries into the synergistic or antagonistic nature of the treatments. While the combination appeared beneficial, the exact ratio remained undetermined in the literature.
The focus was on using Botulinum toxin before energy-based devices and lasers in Chat Generative Pre-Trained Transformer (ChatGPT) imaging. The investigator explored the optimal timeline for toxin application during treatment sessions, with some suggesting administration ten minutes after injection. A pivotal study by Susie Kilmer, published in Derm Surgery in 2005, found no reduction in efficacy when employing pulse dyelaser, Smooth beam, Cool Glide, radiofrequency, and IPL devices alongside Botulinum toxin. The significant study provided critical insights into appropriate combinations and practices. Additionally, a study published in the Journal of Cosmetic Dermatology on October 23 analyzed a clinical trial involving 45 women who received Botulinum toxin and radiofrequency microneedling in the same area of the crow's feet. The study included a control group treated with Botulinum toxin alone, as well as groups where Botulinum toxin was administered within three days post-microneedling and more than seven days after the procedure. The control group received only Botulinum toxin .
. As anticipated, improvements were observed due to the administration of botulinum toxin. However, when the injection distance was insufficient, results were less pronounced. The wrinkle score in the control group was significantly higher three days post-microneedling than that of BTX alone. The wrinkle score returned to baseline after repeated injections after seven days. Additionally, the study demonstrated that injecting BTX in the same area concurrently with radiofrequency microneedling inhibited the activity of the toxin. The finding was corroborated by histological data from mouse muscle biopsies, which exhibited varying degrees of atrophy based on the timing of the interventions. The control group received no treatment, while the radiofrequency microneedling group displayed changes akin to those observed with no treatment. Moreover, simultaneous application of microneedling and BTX resulted in a significant reduction in the efficacy of the toxin. Although the toxin's effectiveness was not as compromised as in the absence of microneedling, the reduction was notable when interventions were performed immediately, 24 hours, two days, three days, and seven days after the microneedling procedure.
In conclusion, the concurrent use of BTX and laser energy-based devices in the same area is safe if they are not performed in the same session. The administration of BTX before full laser resurfacing appeared to be synergistic, as it improved wound healing. However, it was recommended that BTX be injected two, three, or four weeks before the procedure to mitigate the risk of post-inflammatory hyperpigmentation. Incorporating a small amount of toxin into fractional ablative procedures was suggested to enhance wound healing and reduce the risk of inflammatory hyperpigmentation. The effects and safety of microneedling devices remained unclear, with potential surprises anticipated in the future. In practice, the author treated patients with botulinum toxin, waited one week, and then utilized laser and energy-based devices. Administration of toxins was done every three to four months.
33, European Academy of Dermatology and Venereology Congress, 25-28 September 2024, Amsterdam
