Use of Botulinum Toxin A to Treat Chemotherapy-Induced Raynaud’s Phenomenon

Abstract

Raynaud’s phenomenon (RP) is a vasospastic disorder of the digital blood vessels leading to pain, paresthesias, and pallor in response to cold or stress. RP can develop secondary to a number of pathologies or factors, including the use of chemotherapy agents. Typical first-line therapies for secondary RP may be contraindicated in patients with certain comorbidities. Here, we discuss a case in which botulinum toxin A (BTX-A) was used to treat chemotherapy-induced RP in a patient with non-small cell lung cancer (NSCLC). We provide a review of the existing literature on the clinical course and treatment modalities, including the use of BTX-A, for patients with secondary RP. A 56-year-old female with NSCLC received treatment with bevacizumab and pemetrexed. Her initial symptoms included progressive discoloration and pain in her fingertips, which hastily progressed to ischemia and subsequent dry gangrene. She was diagnosed with chemotherapy-induced RP, but traditional management options were complicated by acute congestive heart failure. BTX-A injections were administered at key locations on the wrist and hand, significantly improving her symptoms and slowing the progression of the gangrenous changes. RP can develop as sequelae of chemotherapy regimens. Clinical management may be complicated by underlying pathology and/or patient symptoms. BTX-A injections are an excellent non-operative therapeutic option for patients with secondary RP in cases where mainstay therapies may be contraindicated, thus decreasing pain, improving patient quality of life, and slowing the progression of gangrenous changes.

The Use of Botulinum Toxin in Raynaud Phenomenon

“…9,15,25,26,43,44 There were 7 case series', including a range of 2 to 11 patients. 4,20,28,31,[35][36][37] There were 15 single case reports, 1,2,5,10,14,17,21,23,24,27,29,32,33,40,46 1 piece of original research, 38 and 1 clinical trial. 45 The largest study was a randomized trial by Motegi et al 26 in 2017, which included 45 patients.…”

“…Figure 2 represents the locations of some of the most commonly used injection techniques from the studies. The most frequently used technique was seen in 42.9% (18 of 42) 2,5,[12][13][14][15]18,19,[21][22][23]26,31,34,36,42,43,45 of the studies in Table 1. These used a method similar to that described by Neumeister in 2009.…”

“…Injections into the palm were reported in 31% (13 of 42) of studies. 2,4,10,11,[15][16][17][18][19][20]24,37,41 Several palmar sites included the superficial palmar arch, distal palmar crease, the area of the common and proper digital arteries and/or the common and proper palmar arteries, but some studies did not specify. Six studies in Table 1 injected into the tissue near the radial and ulnar arteries in the volar wrist crease.…”

“…Six studies in Table 1 injected into the tissue near the radial and ulnar arteries in the volar wrist crease. 2,11,19,38,41,42 Goldberg et al 41 suggest that injecting both the wrist and digits is effective in replicating the effects of surgical sympathectomy and may result in higher digital perfusion. Injection over the ulnar artery additionally reaches the nerve of Henle, which provides sympathetic stimulation to the digits.…”

“…The dose of BT-A injected per hand had the wide range of 10 to 300 units, and no injection site stands out among these studies as a disproportional cause of complications. However, Fregene et al 11 noticed that most of their cases of muscle weakness occurred when injections Subjective patient reported outcomes 23 1,2,4,5,[10][11][12][13][14]16,17,21,23,[27][28][29]32,33,[35][36][37]40,42,46 VAS 22 9,11,16,[18][19][20]22,[24][25][26][29][30][31]34,[37][38][39]41,[43][44][45][46] Ulcer healing 21 4,[11]…”