Download Application in general medicine

HEALTH AND WELLNESS 3/2013
WELLNESS, MIND AND BEAUTY
CHAPTER V
1
Faculty of Nursing and Health Sciences
Medical University of Lublin
Wydział Pielęgniarstwa i Nauk o Zdrowiu
Uniwersytet Medyczny w Lublinie
2
Department of Paediatric Neurology
Clinical Children's Hospital in Lublin
Klinika Neurologii Dziecięcej
Dziecięcy Szpital Kliniczny w Lublinie
3
Clinic of Paediatric Neurology, III Faculty of Paediatrics
Medical University of Lublin
Klinika Neurologii Dziecięcej, III Katedra Pediatrii
Uniwersytet Medyczny w Lublinie
4
Student Medical University of Lublin
Student Uniwersytetu Medycznego w Lublinie
MIROSŁAW JASIŃSKI1,2, EWA ZIENKIEWICZ3, JOANNA DUBELT3,
RENATA KONCEWICZ3, EWA JASIŃSKA4
Various aspects of botulinum toxin use
in cosmetology and medicine
Różnorodne aspekty zastosowania botuliny tężcowej
w kosmetologii i w medycynie
INTRODUCTION
th
In mid-19 century botulinum toxin was declared a poison responsible for severe
and fatal intoxications with botulin. The toxin is produced by an anaerobic bacterium Clostridium botulinum. The first reports regarding a possible use of botulinum
toxin for medical purposes appeared in 1822. In 1989 the American FDA (Food and
Drug Administration) approved use of botulin in therapy of strabismus, eye spasms
(uncontrolled eyelid twitches), uncontrolled muscular contractions.
Botulinum toxin and botulin-based preparations are often associated with cosmetic procedures. However, the drug is also widely used in a broad spectrum of
neurological conditions (e.g., eye spasms, hemifacial spasm, wry-neck, esophageal
achalasia), and ophthalomological problems (e.g., strabismus; nystagmus).
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In cosmetology, botulinum toxin is widely used for removal of skin imperfections. Skin plays an important biological role and “is a way of self-presentation and
presentation to others, and is a cosmetic organ” [1]. In psychological aspect, skin
condition is often underestimated, because of its minor threat to life. However, from
the point of view of definition of health provided by WHO as “a state of complete
physical, mental and social well-being”, healthy skin becomes much more important
[2]. Therefore, healthy skin is an important factor of complete heath and high quality
of life.
Studies of patients with dermatological problems, including psoriasis, systemic
lupus ertthematosus, common acne, acne rosacea or atopic dermatitis, indicate significance of the problem and its unfavorable effect on well-being of studied patients
[3; 4].
Botulinum toxin is a potent natural toxin produced by anaerobic bacteria Clostridium botulinum. Its action is associated with arrest of acetylcholine secretion from
nerve endings (Ryc. 1). Acetylcholine is a neurotransmitter responsible for neuromuscular transmission [5]. The toxin binds to pre-synaptic membrane receptors, then
by endocytosis enters endosomes, and becomes released into cytoplasm, damaging
protein in pre-synaptic vesicles. The process of binding of acetylcholine-containing
pre-synaptic vesicle with postsynaptic membrane becomes blocked, which prevents
release of the neurotransmitter into the synaptic space. Potential of the neuromuscular motor end-plate becomes reduced and a muscle is paralyzed. As a result the muscle is decontracted and relaxed.
Ryc. 1. Action of botulinum toxin (BTX), Source: [6]
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Mirosław Jasiński, Ewa Zienkiewicz, Joanna Dubelt, Renata Koncewicz
Various aspects of botulinum toxin use in cosmetology and medicine
There are seven antigen types of the toxin, marked as: A, B, C, D, E, F, and G.
A, B, E toxins are most commonly responsible for human intoxication following
consumption of contaminated canned food [7].
Administration of botulinum toxin leads to myofibrillar muscular atrophy. Effect
of the toxin is reversible. In about three months the motor end-plate recreates neuromuscular endings and transmission of neuromuscular impulses is restored.
Botulinum toxin-based preparations used in medicine are produced in laboratories from isolated bacterial strains, purified and vacuum-packed in strictly measured
doses. Toxin type A is the most widely used due to its most potent effect.
At first, botulinum toxin was used in ophthalmology, for therapy of cranial nerve
palsies, dystonia, ticks, muscular spasms, urinary incontinence. Botulin was first
used to achieve a neuromuscular block by Scott in 1973. Indications for botulinum
toxin administration have been currently expanded.
APPLICATION IN COSMETIC DERMATOLOGY
In esthetic dermatology botulinum toxin is used for therapy of mimic/dynamic
wrinkles, appearance of which depends on muscular action, mostly in the 1/3 upper
part of the face: transverse wrinkles of the forehead, between eyebrows, around
eyes. Areas of the lower eyelid, mouth, chin and neck, nasolabial fold are less commonly treated that way. Esthetic dermatology uses very low doses of the toxin, and
doses are strictly individually adjusted. They are approximately 20-60 units per a
single procedure. Toxic dose for a human is from 2.5 to 3 thousand units. Therefore,
doses used for cosmetic purposes are much lower that the therapeutic dose and completely safe [7].
In dermatology the toxin is also used for treatment of feet, palms and axillary
hyperhidrosis. It is a rather important problem causing discomfort of affected patients and their surroundings. Locally administered toxin reduces secretion from
sweat glands. Before the local administration a topical anesthesia, intravenous regional anesthesia, nerve block or ice compresses may be applied [8; 9]
The procedure of botulinum toxin injection is a short one. A low volume of the
preparation is injected to several facial locations. Pain associated with the procedure
is minimal. The above mentioned local anesthesia is given about one hour before the
procedure. Botulinum toxin starts acting 2-3 days following its injection. A complete therapeutic effect is observed in 7-14 days, and is maintained for three to six
months. After the toxin effect disappears completely the procedure should be repeated – 2-3 times a year, every 4-6 months. The therapy with botulinum toxin for esthetic purposes is relatively simple and provided in outpatient setting.
Botulinum toxin is also used for therapy of migraine and non-migraine (tension)
headaches. Headache is often accompanied by nausea, vomiting, photophobia, lacrimation, eye reddening, and running nose. The toxin administered into an appropriate forehead and nape areas treats those symptoms [10; 11]
Another indication for the toxin is spastic myalgia, mostly of the neck, nape and
back.
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The toxin is also used in therapy of surgical scars and thoracic muscle tension –
following implantation of breast enlarging implants.
APPLICATION IN GENERAL MEDICINE
Ophthalmology is another field of medicine where botulinum toxin has found its
place, among others for therapy of concomitant convergent and divergent squint and
hyperfunction of the superior rectus muscle. The toxin improves position of eyeballs
and restores normal binocular vision by dissociation of pathologic cortical pathways
and anomalous retinal correspondence, followed by development of new cortical
pathways with normal retinal correspondence. Hypercorrection occurs in 3-4 months
following administration of botulinum toxin, resulting in parallel or close to parallel
position of botyh eyes. Symmetrical stimulation of retina in both eyes causes transmission of correct visual stimuli to corresponding optic centers in the cerebral cortex. According to some studies (E.Oleszczyńska-Prost), the best results were
achieved in therapy of concomitant convergent alternating squint. Slightly less favorable results were achieved in therapy of concomitant divergent squints, and the
least favorable in therapy of hyperfunction of the superior rectus muscle. Binocular
vision is a sine qua non condition of complete cure of strabismus. Application of
botulinum toxin is an alternative for surgical or conservative therapy acc. to the
localization method with prismatic hypercorrection [12].
Congenital nystagmus is a rather common problem encountered in ophthalmological practice. Nystagmus involves horizontal, vertical or rotational, rhythmical
twitching of eyeballs. Two types of nystagmus are: pendular and jumping nystagmus. Causes of congenital nystagmus may lie in the visual organ itself or in the
central nervous system. Congenital nystagmus is of pendular character. Eyeball
movements may be irregular, variable, coarsely waveform; nystagmus may be obscure or overt. The basic features of congenital nystagmus involve abnormal development of fixation and decreased visual acuity. They may be caused by leucoma,
retinal degeneration, congenital cataract or vision-affecting anatomical alterations of
the retina and optic nerve – congenital albinism, achromatopsy, degenerative lesions, post-infectious or post-traumatic changes, optical nerve atrophy. Other causes
may involve abnormalities in development of nerve pathways or cortical centers in
the central nervous system. Botulinum toxin injections constitute the most modern
method used for therapy of nystagmus. Nystagmus is treated conservatively or surgically. Conservative therapy uses prismatic glasses. Surgical therapy is used by
numerous clinicians. The use of botulinum toxin for therapy of nystagmus is not
very common. The procedure causes reduction in range of the nystagmus, but is not
permanent, but requires repeated injections in 3-6 months intervals. According to
E.Oleszczyńska-Prost application of botulinum toxin type A gives inferior results
compared to surgery [13; 14]. According to other authors, early surgical procedures
on four external eye muscles give no permanent results, and should be perfroemed at
the age of 7-8 years [15; 16]. Application of botulinum toxin in young children under the age of 2 years may be favorable, providing reduction of nystagmusassociated movements of the eyeball, improved visual acuity, reduction of compen62
Mirosław Jasiński, Ewa Zienkiewicz, Joanna Dubelt, Renata Koncewicz
Various aspects of botulinum toxin use in cosmetology and medicine
sative head positioning and extension of binocular field of vision. Development of
visual functions is the most intensive in young children, and often defines quality of
vision throughout the whole future life [17].
Botulinum toxin may be successfully used in patients with neurogenic and nonneurogenic urinary system dysfunctions [18; 19]Abnormal urinary bladder function
may be caused by defects and conditions of the nervous system (hence referred to as
“neurogenic bladder”) or occur without a detectable neurological cause. Dysgraphic
spinal defects are responsible for development of neurogenic bladder, associated
with bladder filling sensation disorders and ureter sensation disorders. The condition
leads to inability to empty the bladder in a single portion or urinary inconsistency.
Conservative therapy is often used – periodical catheterization, pharmacological
bladder enlargement combined with reduction of internal pressure. Bladder hyper
reactivity is associated with reduction of bladder functional volume. The condition is
complicated by sudden urges, nycturia, involuntary leaking or night-time incontinency. Additionally, very high pressure in the bladder may lead to recurrent urinary
tract infections and secondary anatomical changes in the urinary system. Conservative therapy consists in pharmacotherapy with anticholinegic agents. Lac of efficacy
is manifested by urinary incontinence. If the conservative therapy proves ineffective,
surgical therapy is the other option – aimed at reconstruction of the urinary system,
involving increasing volume of the bladder and reduction of internal pressure. Surgical cystostomy is used in younger children. Botulinum toxin may be considered as
an alternative method of therapy of bladder-associated disorders in cases of failure
of conservative therapy, hypersensitivity to anticholinergic drugs and refusal of
consent on surgical treatment. Therapy with the toxin consists in a series of injections into detrusor muscle in order to reduce intra-bladder pressure during the phase
of urine accumulation, and intra-sphincter injections in order to alleviate sphincter
coordination abnormalities during the urination. Efficacy of detrusor injections was
noted in 60-80% of patients. Effect of botulinum toxin in the bladder is maintained
for 6 to 12 months.
For many years botulinum toxin has been used in neuromuscular diseases associated with excessive muscular tension. In orthopedics the toxin is successfully used
for therapy of neurogenic subluxation of hip joints in children with spastic paralysis
in course of severe forms of infantile cerebral palsy. Damage of the superior motoneuron during the early developmental phase leads to instability and balance disorders associated with hip joints. A local spasmolytic therapy may allow avoiding
early surgical interventions for hip joint instability in children with infantile cerebral
palsy. Instability in CP is progressive and leads to dislocation. Botulinum toxin is
administered bilaterally. Unilateral effect is contraindicated. According to clinical
trials, preventive use of botulinum toxin for neurogenic dislocation of the hip joint in
children with cerebral palsy extends the period of stability of the hip joint [20].
Botulinum toxin has been also used for therapy of functional contractures. Removal of pathological muscular tension and intensive rehabilitation allows achievement of qualitatively better function of the affected muscle and prevents from contractures. Rehabilitation stimulates the nervous system for creation of new connections and taking functions of affected centers over by healthy ones. Administration
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of botulinum toxin is aimed at improvement of gait, grasping function, efficient selfcare of public areas, pain alleviation, facilitation of rehabilitation procedures and use
of orthoses. A long-term aim is prevention of permanent contractures, development
of physiological motor patterns and normal muscular development [21; 22]
In the spastic form of infantile cerebral palsy dysfunctions of upper extremities
are a result of muscular weakness, sensation disorders, dystonic movements, contractures and spasticity. A patient had troubles with grasping, dropping, aiming and
manipulating. Botulinum toxin tupe A is administered into extremities demonstrating pathological position pattern, e.g. internal rotation and adduction in the ulnar
joint, pronation of the lower arm, “thumb in the palm”, flexion of the wrist. Therapy
with botulinum toxin increases the range of motion and reduces muscular tension
[22]
Before starting therapy of spasticity of lower extremities an attention should be
drawn to the major motor functions: sitting, crawling on all fours, standing and quality of gait. Attributes of normal gait are disturbed in CP patients. A set of tests is
used for evaluation of spasticity. Therapy of lower limb spasticity with botulinum
toxin brings the best effects between the 1st and 5th year of life. Available literature
data indicate that the therapy with the toxin should be started at the age of 1-2 years
and continued until the age of 8-10 years. A complete cycle of rehabilitation is recommended following each session of injections. Selection of appropriate orthoses
and corrective splints is also important.
Physiological gait is a set of precisely controlled actions, coordinated and repeatable movements of extremities and of the trunk. Studies indicate that active training
of spastic muscles in children with cerebral palsy has a positive effect on their function. There is evidence that a more intensive training improves efficacy of gait function. Automatic orthoses allow increase of frequency of task-specific training, walking speed and variability. Botulinum toxin injection a month before the start of the
therapy may favorably influence its final effect [23].
In cerebral palsy not all muscles are equally affected. A constant prevalence of
one muscles leads to osteoarticular deformations. Botulinum toxin is administered to
relax muscles spasticity of which hinders a motor activity of a child (gait) and to
avoid orthopedic deformities. Administration of botulinum toxin leads to improvement of range of motion and of spatial-temporal parameters of gait. Rehabilitation in
the system of directed teaching following administration of botulinum toxin is a new
element of that work.
Spasticity may cause disability following a cerebral stroke, in sclerosis multiplex, or in case of spinal cord injury [24]. Spasticity may be the main cause of pain.
Untreated or mistreated leads to complications, including muscular contractures. A
problem of spasticity has to be solved in a multi-disciplinary fashion. A patient has
to be familiar with his/her problem [25]. Physiotherapy should be appropriately
implemented. Causal treatment of spasticity is aimed at function improvement, reduction of risk of complications, pain alleviation. 1) Patient education regards simple actions that may intensify the spasticity: improper sitting, platypodia, improper
shoes. Bed-ridden patients with consciousness disorders are at risk of infections,
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Mirosław Jasiński, Ewa Zienkiewicz, Joanna Dubelt, Renata Koncewicz
Various aspects of botulinum toxin use in cosmetology and medicine
urinary tract infections, constipations, fractures of lower extremities. 2) Physiotherapy – knowledge of correct body posture, correct sitting, prosthesis adjustment. The
lying position increases muscular tension. 3) Pharmacotherapy: oral drugs – diazepam, baclofen, dantrolene, tizanidine, gabapentin. 4) Local therapy: botulinum toxin
type A, botulinum toxin type B – in case of presence of antibodies reducing the
effect of botulinum toxin type A. 5) Intrathecal administration of baclofen. 6) Surgical therapy: rhizotomy, peripheral nephrectomy, cordectomy, myotonia, cerebellar
and medullary stimulator implantation.
Spasticity may be also treated using various techniques: from oral drugs to botulinum toxin.
LITERATURE
1. Żelazny, I., Nowicki, R., Majkowicz, M., & Samet, A. (2004). Jakość życia w
chorobach skóry. Przewodnik lekarza (9).
2. World Health Organization. (1947). The constitution of the World Health
Organization. N.Y.: WHO Chron.
3. Feldman, S., Fleicher, A., Reboussin, D., Rapp, S., & Bradham, D. (1977). The
economic impact of psoriasis increases with psoriasis severity. J Am Acad
Dermatol (37), 564-569.
4. Janowski, K. (2007). Problematyka jakości życia w chorobach dermatologicznych. Jakość życia w chorobie. Lublin: Wyd. KUL.
5. Domżał, T. (2002). Toksyna botulinowa w praktyce lekarskiej. Lublin: Wyd.
Czelej.
6. Olver, J. (2001). Colour Atlas of Lacrimal Surgery . Oxford: Elsevier LTD, .
7. Lang, A. (2003). Botulinum toxin type A therapy in chronic pain disorders. Arch
Phys Med Rehabil. , 3 (Suppl 1) (84), pp. 69-73.
8. deMaio, M., & Rzany, B. (2007). Botulinum Toxin in Aesthetic Medicine.
Heidelberg: Springer.
9. Heckmann, M., Ceballos-Baumann, A., & Plewig, G. (2001). Botulinum toxin A
for axillary hyperhidrosis (excessive sweating). N Engl J Med , 7 (15), pp. 488493.
10. Stefaniak, T., Cwigon, M., & Łaski, D. (2012). In the search for the treatment of
compensatory sweating. Scientific World Journal (134547).
11. Freitag, F. (2003). Preventative treatment for migraine and tension-type
headaches : do drugs having effects on muscle spasm and tone have a role? CNS
Drugs, 6 (17), pp. 373-381.
12. Göbel, H. (2004). Botulinum toxin in migraine prophylaxis. J Neurol, (Suppl 1)
(251), pp. 8-11.
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13. Oleszczyńska-Prost, E. (2011). Toksyna botulinowa w leczeniu zeza
towarzyszącego i oczopląsu u dzieci. Poznań: Polskie Towarzystwo Okulistyczne.
14. Oleszczyńska-Prost, E. (2011). Centrum Okulistyki Dziecięcej - Biuletyn
okulistyczny. Retrieved 12 20, 2012, from Centrum Okulistyki Dziecięcej:
http://www.okulistykadziecieca.pl/?biuletyn
15. Oleszczyńska-Prost, E. (2004). Botulinum toxin A in the treatment of
concomitant strabismus in children. Klin Oczna , 1-2 (106), pp. 64-67.
16. Lennerstrand, G., Nordbø, O., Tian, S., Eriksson-Derouet, B., & Ali, T. (1998).
Treatment of strabismus and nystagmus with botulinum toxin type A. An
evaluation of effects and complications. Acta Ophthalmol Scand, 1 (76), pp. 2737.
17. Rayner, S., Hollick, E., & Lee, J. (1999). Botulinum toxin in childhood
strabismus. Strabismus, 2 (7), pp. 103-111.
18. Crouch, E. (2006). Use of botulinum toxin in strabismus. Curr Opin Ophthalmol,
5 (17), pp. 435-440.
19. H.C., K. (2003). Effect of botulinum A toxin in the treatment of voiding
dissfunction due to detrusor underactivity. Urology , 3 (170), p. 1048.
20. Kroll, P. (1999). Niefarmakologiczne metody terapii zaburzeń czynnościowych
pęcherza i cewki moczowej. In A. Jankowski (Ed.), Badania Urodynamiczne u
Dzieci. Poznań: Stowarzyszenie Pomocy Dzieciom Wymagającym Leczenia
Chirurgicznego.
21. Czupryna, K., Pietruszewski, J., & Poliszuk-Siedlecka, M. (2006). Mozliwości
łagodzenia zaburzeń chodu u dzieci z mózgowym porazeniem dziecięcym
usprawnianych i leczonych toksyna boyulinową w swietle trójwymiarowej
analizy chodu. Neurologia Dziecięca (15), pp. 17-25.
22. Gage, J., & Novacheck, T. (2001). An update on the treatment of gait problems
in cerebral palsy. J Pediatr Orthop B. , 4 (10), pp. 265-274.
23. Jóźwiak, M., Harasymczuk, P., & Ciemieniewska-Gorzela, K. (2007). Zastosowanie toksyny botulinowej typu A w leczeniu neurogennego podwichnięcia
stawów biodrowych u dzieci z tetraplegią spastyczną w przebiegu mózgowego
porażenia. Chirurgia Narzadów Ruchu i Ortopedia Polska, 3 (72), pp. 205-209.
24. Suheda, O., & Koncuy, S. (2007). Botulinum Toxin in Poststroke Spasticity.
Clin Med Res, 2 (5), pp. 132-138.
25. Zak, E., Durmała, J., Sobota, G., & Głowacka, A. (2010). Trening z
zastosowaniem zautomatyzowanej ortozy u dziecka z diplegią po uzyciu toksyny
botulinowej - studium przypadku. Acta Bio-Optica et Informatica Medica, 16
(3).
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Various aspects of botulinum toxin use in cosmetology and medicine
ABSTRACT
Botulinum toxin type A is the best known and the most widely used drug used in
medicine, not only esthetic medicine. The drug effectively improves the quality of
life for patients with chronic neurological or ophthalmologic disorders, improving
their social status and preventing their exclusion. An equally important role is
played by botulinum toxin and its preparations in cosmetology. Botulinum-based
preparations are very popular in removing orbital wrinkles, called crow’s feet. Intramuscular injection of the drug blocks the transmission of nerve impulses, removing facial wrinkles and smoothing the skin of the face, neck, and reducing sweating.
It can be used several times, depending on the age and nature of the patient's skin. In
the present study, authors attempt to present selected, the most important – from
their point of view - aspects of the use of botulinum toxin in cosmetology and medicine.
STRESZCZENIE
Najbardziej znanym i popularnym lekiem stosowanym w medycynie nie tylko
estetycznej jest toksyna botulinowa typu A. Jej zastosowanie skutecznie wpływa na
poprawę, jakości życia pacjentów z przewlekłymi schorzeniami neurologicznymi
lub okulistycznymi, poprawiając ich status społeczny i zapobiegając ich
wykluczeniu. Równie ważną rolę botulina i jej preparaty odgrywają w kosmetologii.
Jest bardzo popularna w likwidowaniu zmarszczek około oczodołowych, zwanych
kurzymi łapkami. Podawana domięśniowo blokuje przekazywanie impulsów
nerwowych, co powoduje spłycenie i wygładzenie zmarszczek mimicznych skóry
twarzy, szyi oraz zmniejszenie wydzielania potu. Może być stosowana wielokrotnie,
w zależności od wieku i rodzaju skóry pacjenta. W prezentowanej pracy autorzy
pojęli próbę zaprezentowania kilku najważniejszych ich zdaniem aspektów
zastosowania botuliny tężcowej w kosmetologii i w medycynie
Artykuł zawiera 23240 znaków ze spacjami + grafika
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