10.5826/dpc.1301a32
text/xml
2160-9381
2488
en
Ercan Caliskan
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
botulinum toxin
Facial Bier Spots Unresponsive to Botulinum Toxin: A Case Series
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2023-01-31
2022-03-23
2023-01-31
2023-03-01
e2023032
Dermatol Pract Concept
Ercan Caliskan
2023/01/31
10.5826/dpc.1301a32
e2023032
Department of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey
2160-9381
botulinum toxin
en
e2023032
Grando S, Zachary C. The non‐neuronal and nonmuscular effects of botulinum toxin: an opportunity for a deadly molecule to treat disease in the skin and beyond. Br J Dermatol. 2018;178(5):1011-1019. DOI: 10.1111/bjd.16080. PMID: 29086923.
Facial Bier Spots Unresponsive to Botulinum Toxin: A Case Series
https://dpcj.org/index.php/dpc/article/download/2488/1970
 Facial Bier Spots Unresponsive to Botulinum Toxin:
                    A Case Series
                        Pelin Esme1, Burcu Beksac1, Gulsen Akoglu1, Ercan Caliskan1


1 Department of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey



Key words: Bier spots, angiospastic macules, face, botulinum toxin
Citation: Esme P, Beksac B, Akoglu G, Caliskan E. Facial Bier Spots Unresponsive to Botulinum Toxin: A Case Series. Dermatol Pract
Concept. 2023;13(1):e2023032. DOI: https://doi.org/10.5826/dpc.1301a32
Accepted: June 9, 2022; Published: January 2023
Copyright: ©2023 Esme et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non
Commercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Pelin Eşme, MD, Department of Dermatology and Venereology, University of Health Sciences, Gulhane Training
and Research Hospital, 06010, Kecioren, Ankara, Turkey, +9 0 312 304 44 67 Fax number: +9 0 312 304 27 00, pelinnesme@gmail.com




Introduction                                                             emotional stress and bending down. He also suffered from
                                                                         headaches and forehead wrinkles. A diagnosis of Bier spots
Bier spots are asymptomatic, irregular anemic macules in a               was made upon clinical examination. Laboratory evalu-
blanchable erythematous background. However, the patho-                  ations and imaging methods revealed no abnormalities.
genesis is not clear yet; abnormal vasoconstriction of vessels           A total of 150 Speywood units (reconstituted with 2.5 ml
has been suggested as the primary mechanism [1]. Lesions                 normal saline) of botulinum toxin (AbobotulinumtoxinA,
often involve extremities and the trunk; only one case with              Dysport®, Ipsen, 500 units) were injected to forehead lines
facial involvement has been reported previously [2]. Lesions             considering the localization of Bier spots (Figure 1). In addi-
do not require specific treatment, but patients may experi-              tion to cosmetic improvement of the frontal wrinkles within
ence cosmetic problems [3].                                              one week, headache severity regressed from 10 to 5 points
    Herein, we described 3 cases with Bier spots on the face             according to the visual analog scale (VAS) for pain. Unfor-
with accompanying tension-type headaches in all patients                 tunately, there was no response in Bier spots six weeks after
and tested the hypothesis that botulinum toxin might im-                 botulinum toxin injection.
prove facial Bier spots.                                                      The symptoms of a 48-year-old male patient (Patient 2)
                                                                         started one year ago on the trunk and face without any trig-

Case Presentation                                                        gering (Figure 2). A 32-year-old female patient (­Patient 3) had
                                                                         experienced similar complaints on the forehead six months
A 45-year-old male patient (Patient 1) was admitted to our               after her first vaginal delivery. Strikingly, both were accom-
outpatient dermatology clinic with a complaint of pale,                  panied by tension-type headaches. Laboratory evaluations
whitish macules on the forehead. The complaints had started              and imaging methods of both patients did not reveal any
six months ago after trauma and become more visible with                 abnormality.




Research Letter | Dermatol Pract Concept. 2023;13(1):e2023032                                                                          1
Figure 1. Case 1. (A) Pretreatment. Bier spots were marked with black color to orient the injector. The hypopigmented macule highlighted
with a red arrow was selected as a control area, and no injection was performed. (B) Post-treatment. Significant improvement was recorded
in forehead lines at week 1, while there was no improvement in Bier spots.




                           Figure 2. Case 2. The patient provoked these lesions by holding his breath for about
                           a half minute and bending down just before the photographs.



2                                                                          Research Letter | Dermatol Pract Concept. 2023;13(1):e2023032
   Botulinum toxin injections were performed to Bier spots      References
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vasoconstrictive response [1,6]. However, while tension-type       effects of botulinum toxin: an opportunity for a deadly mol-
headaches in both patients improved, Bier spots did not.           ecule to treat disease in the skin and beyond. Br J Dermatol.
                                                                   2018;178(5):1011-1019. DOI: 10.1111/bjd.16080. PMID:
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more critical than the exaggerated vasoconstrictive response.




Research Letter | Dermatol Pract Concept. 2023;13(1):e2023032                                                                     3
