Botulinum toxin represents one of the most frequently requested cosmetic procedures. We treated 223 patients with facial wrinkles using a new technique of injection of botulinum toxin A (BTA) called multipoint and multilevel injection technique (MMIT). The aim of MMIT was to relax the muscle and not paralyze it. Patient satisfaction was evaluated by Facial Line Treatment Satisfaction Questionnaire (FTSQ). Treatment with botulinum toxin determined a good response in all patients. Facial rhytids were completely resolved in case of young skin and well reduced in case of aged skin, leaving a natural aspect both in static and dynamic wrinkles. Patient mean overall satisfaction evaluated with FTSQ was 6.4 ± 1.1. In our experience, the use of botulin toxin by MMIT consents a better calibration of action with a soft and natural result. This can be achieved by distributing the BTA dose through various injection points for each area ("multipoint injections"). Furthermore, injections can be performed at different levels ("multilevel injections"). The level of injections regulates the potency of effect on the muscle: if the level is deep (intramuscular), the effect will be strong while if it is medium or superficial (subcutaneous and intradermal), the effect will be soft. This consents a fine calibration of action on muscle activity with a personal aesthetic result.

Dear Editors,Bullous pemphigoid (BP) is a common subepidermal autoimmune bullous disease. A number of external agents have been associated with its development, including trauma, thermal burns, skin grafts, radiotherapy, ultraviolet exposure (UVB, PUVA), photodynamic therapy, surgery, vaccination and cutaneous infections. An 85-year-old woman presented with a two-month history of blistering lesions on the back, legs and abdomen ( Figure 1). She complained generalized itch and had widespread erosions and crusts on erythematous skin. Remarkably, all the lesions appeared on thermal burn scars (some of which had been covered with meshed split-thickness autografts 20 months before) and on donor sites. Her medical history included hypertension and atrial fibrillation and she had been treated with a calcium channel blocker and warfarin for several years. Skin biopsies from both scar area and donor site revealed a subepidermal detachment and superficial dermal infiltrate consisting of lymphocytes and eosinophils. Direct immunofluorescence showed linear deposits of IgG and C3 at the basement membrane and BP180 ELISA was positive, confirming the diagnosis of localized BP.

Necrotizing vasculitis is a complex phenomenon because of an inflammation of small and larger vessels with polymorph infiltration within the vessel walls and leukocytoclasis, occurring in several autoimmune diseases. Propylthiouracil (PTU) is a medication commonly used to treat hyperthyroidism, but it is associated with various rare side effects, such as antineutrophil cytoplasm antibody-positive vasculitis. In the last decades, multiple cases of PTU causing antineutrophilic cytoplasmic antibody have been reported, some of them fatal. The present authors report the case of a 34-year-old Caucasian female affected by autoimmune hyperthyroidism treated with PTU, presenting an antineutrophil cytoplasm antibody-positive necrotizing vasculitis, with high levels of anticardiolipin antibodies that involved the upper arms and buttocks. The clinical manifestations improved after discontinuing of PTU and immunosuppressant treatment.

Injection of botulinum toxin can treat entropion and resulted in a significantly high success rate.