Background/Purpose

Raynaud’s phenomenon (RP) is characterized by transient episodes of vasoconstriction of the arteries and arterioles of the extremities in response to cold or emotional stimuli. Depending on the severity of the vascular insult, it can cause superficial ulceration or deep-tissue necrosis. Pharmacological treatments aim to enhance blood flow but their efficacy is not uniform.

Methods

We present a series of 7 patients with Raynaud’s phenomenon with bad response to conventional pharmacological therapy that have been treated with local botulinum neurotoxin-A. Patients’ characteristics are summarized in table 1. Exclusion criteria included botulinum toxin allergy, active infection at the site of injection, previous digital sympathectomy and pregnancy.

A cumulative total dose of 30-60 units of botulinum toxin was injected into the palmar aspect of the hand. Prior to infiltration, obstructive pathology was ruled out by Doppler ultrasound; also, a nailfold capillaroscopy test was performed before and after the infiltration. Variables such as the number of episodes per day, pain during the episodes, recuperation time, finger color and presence of digital ulceration or necrosis have been studied baseline, 30 minutes, one week and one month after the infiltration.

Results

30 minutes after infiltration, three patients felt no improvement, two assessed slight improvement and two very important improvement. At the patients’ one-week and thirty-days follow-up visits two patients did not perceive any change and four experienced great amelioration. Patients that did not register any change where those with fewer subjective clinical complaints and normal Doppler ultrasound and capillaroscopy tests.

The variable with the most remarkable response was pain, with important pain decrease in all of the cases. Three patients presented digit ulcers at baseline visit; ulceration healing was noted in all of them, two of them one week after the injection and the other one, one month after.

Three patients reported mild “weakness” after being injected and one reported slight thenar-eminence pain that lasted a few days. None of the patients suffered any systemic complications related to the toxin.

Conclusion

Botulinum toxin-A is a safe and effective therapeutic option for patients with severe Raynaud’s phenomenon that have failed to conventional treatment.

Table 1

CREST: Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia

MCTD: mixed connective tissue disease