Update on Melasma-Part II: Treatment.

Melasma is a prevalent chronic relapsing pigmentary disorder that affects photoexposed areas, especially in women of childbearing age. Although there is currently no curative treatment available for melasma, this manuscript critically reviews the knowledge regarding photoprotection, topical and oral therapies, and procedures such as peelings, laser, and microneedling that represent the main strategies for control and prevention of this disease. As the pathogenesis of melasma is not entirely understood, there are prospects for the development of new therapeutic strategies that might act on the pathways that promote sustained pigmentation rather than merely decreasing melanin synthesis and removing melanin from the epidermis.

Update on Melasma-Part I: Pathogenesis.

Melasma is a multifactorial dyschromia that results from exposure to external factors (such as solar radiation) and hormonal factors (such as sex hormones and pregnancy), as well as skin inflammation (such as contact dermatitis and esthetic procedures), in genetically predisposed individuals. Beyond hyperfunctional melanocytes, skin with melasma exhibits a series of structural and functional alterations in the epidermis, basement membrane, and upper dermis that interact to elicit and sustain a focal hypermelanogenic phenotype. Evolution in the knowledge of the genetic basis of melasma and the cutaneous response to solar radiation, as well as the roles of endocrine factors, antioxidant system, endothelium proliferation, fibroblast senescence, mast cell degranulation, autophagy deficits of the melanocyte, and the paracrine regulation of melanogenesis, will lead to the development of new treatments and preventive strategies. This review presents current knowledge on these aspects of the pathogenesis of melasma and discusses the effects of specific treatments and future research on these issues.

Histological changes in facial melasma after treatment with triple combination cream with or without oral tranexamic acid and/or microneedling: A randomised clinical trial.

Background Melasma is an acquired dyschromia with several histologic alterations in the epidermis, basement membrane and upper dermis. The treatment of melasma is challenging due to the irregular response and chronicity of the disease. To date, there are no curative strategies, largely due to the limited understanding of the intrinsic effects of each treatment. Objectives The objective of the study was to evaluate the histological changes promoted by triple combination cream, with or without complementary treatment with microneedling and oral tranexamic acid, in the treatment of melasma. Methods A factorial, randomised, controlled and evaluator-blinded clinical trial was performed involving 64 women with facial melasma, divided in four groups, who underwent 60 days of treatment with triple combination cream alone (control group) or combined with two monthly microneedling sessions (microneedling group), TA 250 mg twice daily (tranexamic acid group), or both tranexamic acid group and microneedling group. The participants underwent biopsy of the area with melasma at inclusion (D1) and D60. The primary outcomes were the variation (D1 × D60) between the variables: Thickness of the epidermis and stratum corneum, stratum corneum compaction and solar elastosis; melanin density in the epidermis and upper dermis; proportion between the extension of the nonintact and intact basement membrane zone; mast cell count in the upper dermis; melanocyte count in the basal layer, pendulum melanocyte count and melanocyte area; immunostaining density of vascular endothelial growth factor; stem cell factor and keratinocyte growth factor. Results One participant in the TG discontinued tranexamic acid due persistent headache; and herpes simplex occurred in three patients after microneedling. The groups showed a 24% (CI95%: 17-35%; P < 0.01) reduction in epidermal melanin density. There was no change in dermal melanin density or the area of melanocytes after treatment. There was an overall 25% (CI95%: 7-42%; P < 0.01) reduction in the number of pendulum melanocytes, especially in the microneedling and tranexamic acid group, that presented a 41% (CI95%: 7-73%; P < 0.01) reduction. The extension of the nonintact basal membrane relative to the intact basal membrane decreased after treatment, especially in microneedling group and microneedling and tranexamic acid group. There was an increase of 13% (CI95%: 5-21%; P = 0.02) in epidermal thickness and 6% (CI95%: 0-22%; P = 0.04) thinning of the stratum corneum in the groups. All groups showed stratum corneum compaction. Solar elastosis improved only in the microneedling group and microneedling and tranexamic acid group. Vascular endothelial growth factor immunostaining increased 14% (CI95%: 4-24%; P = 0.03) in the groups; and stem cell factor increased only in microneedling group. There was no change in the number of mast cells, CD34 and keratinocyte growth factor immunostaining. Limitations The site of biopsy may not represent all of the facial melasma and the immunohistochemical sensitivity of the cytokines does not have a stoichiometric relationship with proteins. Conclusion A greater thickness of the epidermis is associated with melasma bleaching. Dermal melanin seems to have no impact on melasma prognosis. Damage to the skin barrier and stimulus of angiogenesis should be avoided in the treatment of melasma. Microneedling complements the topical treatment of melasma by improving patterns of skin photoaging. Oral tranexamic acid complements the topical treatment of melasma by inhibiting the stem cell factor.

Low-dose oral isotretinoin for moderate to severe seborrhea and seborrheic dermatitis: a randomized comparative trial.

BACKGROUND: The efficacy of low-dose oral isotretinoin in the treatment of seborrhea and seborrheic dermatitis has been poorly investigated in randomized studies. OBJECTIVES: This study was designed to determine the efficacy and safety of low-dose oral isotretinoin in the treatment of moderate to severe seborrhea and seborrheic dermatitis on the scalp and/or face. METHODS: A randomized, comparative clinical trial, using two groups, was conducted over 6 months. Patients in Group ISO were treated with isotretinoin 10 mg every other day. In Group X, patients received antiseborrheic topical treatment. Patient opinion, investigator assessment, scalp pruritus, sebum production, and quality of life (QoL) comprised the efficacy outcomes. RESULTS: The intention-to-treat population comprised a total of 45 patients with mean ± standard deviation ages of 28.7 ± 5.8 years in Group ISO and 29.8 ± 6.5 years in Group X. The rate of sebum production significantly decreased in Group ISO. Patient opinion, investigator, and QoL assessments improved in both groups. CONCLUSIONS: Low-dose oral isotretinoin can be a therapeutic modality for moderate to severe seborrhea and seborrheic dermatitis.

Tratamento da acne vulgar moderada a grave com isotretinoína oral similar ao produto referência / Treatment of moderate to severe acne vulgaris with an oral isotretinoin similar to the reference product

Introdução: Acne vulgar é doença inflamatória crônica dos folículos pilossebáceos. O tratamento deve ser precoce e efetivo para evitar cicatrizes e repercussões psicossociais, sendo a isotretinoína droga de escolha para casos moderados ou graves. Objetivos: Avaliar eficácia, segurança e tolerabilidade de uma isotretinoína similar ao produto referência. Métodos: Estudo bicêntrico, de intervenção terapêutica, incluindo 50 participantes, de 13 a 35 anos de idade, com acne moderada ou grave, usando isotretinoína 0,5mg/kg/dia, até 120mg/kg. A eficácia foi avaliada por meio da contagem de lesões, escala de avaliação global do investigador (IGA), satisfação do paciente e aplicação do questionário de qualidade de vida específico para acne (Acne Qol). Segurança e tolerabilidade foram avaliadas pela análise de eventos adversos e por exames laboratoriais. Resultados: A idade média foi 20 anos, sendo 70% homens, com redução de 99% das lesões ao final do tratamento e remissão total das lesões em 91,5% dos participantes. A escala IGA reduziu 98% no escore ao final do tratamento. Todos os pacientes se declararam satisfeitos, com significativa melhora na qualidade de vida. Os eventos adversos foram semelhantes aos descritos na literatura. Conclusões: A isotretinoína avaliada mostrou-se igualmente eficaz, segura e bem tolerada quando comparada aos dados publicados referentes ao produto-padrão.

Introduction: Acne vulgaris is a chronic inflammatory disease of the pilosebaceous follicles. Treatment should be early and effective to prevent scarring and psychosocial effects, and isotretinoin is the drug of choice for moderate or severe cases. Objective: To assess efficacy, safety and tolerability of an isotretinoin similar to the reference product. Methods: A bicentric study, with therapeutic intervention was conducted, including 50 participants aged 13 to 35 years, with moderate to severe acne, using isotretinoin 0.5 mg/kg/day up to 120 mg/kg. Efficacy was assessed through lesions counting, the investigator's global assessment (IGA) scale, patient satisfaction and application of the quality of life questionnaire specific for Acne (Acne Qol). Safety and tolerability were assessed by analysis of adverse events and laboratory tests. Results: Mean age was 20 years, 70% of participants were men, with a reduction of 99% of lesions after treatment and complete remission of lesions in 91.5% of participants. IGA scale reduced 98% in the score after treatment. Also, 100% of participants declared to be satisfied, with significant improvement in quality of life. Adverse events were similar to those described in the literature. Conclusion: The assessed isotretinoin was equally effective, safe and well-tolerated when compared with published data of the standard product.

Acne-specific quality of life questionnaire (Acne-QoL): translation, cultural adaptation and validation into Brazilian-Portuguese language.

BACKGROUND: many studies about the psychosocial impact of acne have been reported in international medical literature describing quality of life as a relevant clinical outcome. It is well known that the patient's perception about the disease may be different from the physician's evaluation. Therefore, it is important to use validated instruments that turn the patient's subjective opinion into objective information. OBJECTIVES: to translate into Brazilian-Portuguese language and to culturally adapt a quality of life questionnaire, the Acne-Specific Quality of Life Questionnaire (Acne-QoL), as well as to evaluate its reliability and validity. METHODS: measurement properties were assessed: 1) validity: comparison between severity and Acne-QoL domain scores, correlations between acne duration and Acne-QoL domain scores, and correlation between Acne-QoL domain scores and SF-36 components; 2) internal consistency: Cronbach's α coefficient; 3) test-retest reproducibility: intraclass correlation coefficient and Wilcoxon test. RESULTS: Eighty subjects with a mean age of 20.5 ± 4.8 years presenting mild (33.8%), moderate (36.2%) and severe (30%) facial acne were enrolled. Acne-QoL domain scores were similar among the different acne severity groups except for role-social domain. Subjects with shorter acne duration presented significant higher scores. Acne-QoL domains showed significant correlations, both between themselves and with SF-36 role-social and mental health components. Internal consistency (0.925-0.952) and test-retest reproducibility were considered acceptable (0.768-0.836). CONCLUSIONS: the Brazilian-Portuguese version of the Acne-QoL is a reliable and valid satisfactory outcome measure to be used in facial acne studies.

Acne-specific quality of life questionnaire (Acne-QoL): translation, cultural adaptation and validation into Brazilian-Portuguese language

BACKGROUND: many studies about the psychosocial impact of acne have been reported in international medical literature describing quality of life as a relevant clinical outcome. It is well known that the patient's perception about the disease may be different from the physician's evaluation. Therefore, it is important to use validated instruments that turn the patient's subjective opinion into objective information. OBJECTIVES: to translate into Brazilian-Portuguese language and to culturally adapt a quality of life questionnaire, the Acne-Specific Quality of Life Questionnaire (Acne-QoL), as well as to evaluate its reliability and validity. METHODS: measurement properties were assessed: 1) validity: comparison between severity and Acne-QoL domain scores, correlations between acne duration and Acne-QoL domain scores, and correlation between Acne-QoL domain scores and SF-36 components; 2) internal consistency: Cronbach's α coefficient; 3) test-retest reproducibility: intraclass correlation coefficient and Wilcoxon test. RESULTS: Eighty subjects with a mean age of 20.5 ± 4.8 years presenting mild (33.8%), moderate (36.2%) and severe (30%) facial acne were enrolled. Acne-QoL domain scores were similar among the different acne severity groups except for role-social domain. Subjects with shorter acne duration presented significant higher scores. Acne-QoL domains showed significant correlations, both between themselves and with SF-36 role-social and mental health components. Internal consistency (0.925-0.952) and test-retest reproducibility were considered acceptable (0.768-0.836). CONCLUSIONS: the Brazilian-Portuguese version of the Acne-QoL is a reliable and valid satisfactory outcome measure to be used in facial acne studies. .

Perforating granuloma annulare mimicking papulonecrotic tuberculid.

A case is reported of a patient presenting lymph node tuberculosis and cutaneous lesions resembling papulonecrotic tuberculid, but histologically compatible with perforating granuloma annulare and which responded satisfactorily to antituberculous therapy. This is probably one of the first reports of the association of perforating granuloma annulare and tuberculosis, and it is important therefore to highlight the relevance of this disorder in the differential diagnosis of papulonecrotic tuberculid and to raise the hypothesis that this entity should also be considered to be a variant of tuberculid.

Perforating granuloma annulare mimicking papulonecrotic tuberculid / Granuloma anular perfurante simulando tuberculide papulo-necrotica

A case is reported of a patient presenting lymph node tuberculosis and cutaneous lesions resembling papulonecrotic tuberculid, but histologically compatible with perforating granuloma annulare and which responded satisfactorily to antituberculous therapy. This is probably one of the first reports of the association of perforating granuloma annulare and tuberculosis, and it is important therefore to highlight the relevance of this disorder in the differential diagnosis of papulonecrotic tuberculid and to raise the hypothesis that this entity should also be considered to be a variant of tuberculid.

Os autores relatam o caso de uma paciente com tuberculose ganglionar e lesões cutâneas clinicamente sugestivas de tubercúlide pápulo-necrótica, porém com histopatologia compatível com granuloma anular perfurante, e que apresentaram melhora após tratamento para a tuberculose. Trata-se, possivelmente, de um dos primeiros relatos da associação de granuloma anular perfurante com tuberculose, salientando a importância desta entidade no diagnóstico diferencial da tubercúlide pápulo-necrótica e levantando a possibilidade da mesma ser considerada, também, uma variante de tubercúlide.

A randomized and controlled trial about the use of oral isotretinoin for photoaging.

Topical retinoids are used to treat photoaging; oral isotretinoin is gold standard for acne; "off label" indications, including photoaging, have been reported with insufficient evidence of efficacy. This is a randomized controlled phase II trial with clinical and histological assessment to evaluate efficacy and safety of oral isotretinoin for photoaging. Study population was comprised of 32 menopausal or sterilized women, aged 40-55, divided in 2 groups: A (21) received 20mg isotretinoin, 3 times per week, nightly moisturizer, and daily sunscreen, for three months; B (11) just moisturizer/sunscreen. Main outcome measures were: overall clinical assessment; profilometry, corneometer and elasticity tests in periocular regions and left forearm; before/after biopsies from left forearm in patients of B and in 10 randomly selected of A. Microscopic blinded evaluation of epidermal thickness, dermal elastosis, new collagen, p53 epidermal expression was performed by quantitative digital image analysis. All data were submitted to statistical analysis. Clinical evaluation showed slight improvement; profilometry, corneometer and skin elasticity tests presented significant difference in pre/post values (P = 0.001 to 0.028), but no differences between A/B. Histological findings and p53 expression were comparable between groups before treatment (P > 0.1); microscopic analysis showed no differences between groups for most variables, after treatment. Slight but significant difference between A/B for p53 with major reduction post isotretinoin [0.66+/-0.31 vs. 0.94+/-0.34 respectively (P = 0.04) was observed. There were minor side effects and no significant laboratory test alterations. We concluded that no significant clinical, microscopic changes but p53 epidermal expression reduction were observed. The role of ultra-violet induced p53 mutation in skin carcinogenesis reinforces retinoids chemoprevention. Oral isotretinoin seemed safe but not effective to treat photoaging. Caution should be considered for women prone to pregnancy. Further controlled studies are necessary.

Avaliação da segurança e eficácia de novo preenchedor à base de ácido hialurônico no tratamento dos sulcos nasolabiais e contorno dos lábios / Safety and efficacy evaluation of a new hyaluronic acid based filler in the treatment of nasolabial folds and lips outline

Introdução: o uso da técnica de preenchimento cutâneo vem crescendo nos últimos anos. O ácido hialurônico é um dos preenchedores dérmicos temporários mais usados na correção de rugas, linhas e sulcos faciais por ser seguro e eficaz. Objetivo: avaliar a eficácia e segurança do produto Perfectha®, novo preenchedor à base de ácido hialurônico, para a correção dos sulcos nasolabiais e contorno dos lábios. Métodos: estudo aberto, multicêntrico, não randomizado, não controlado, incluindo 87 mulheres saudáveis.A avaliação da eficácia foi realizada através das escalas de melhora estética global (Global Aesthetic Improvement Scale - GAIS) e da classificação de gravidade das rugas (Wrinkle Severity Rating Scale - WSRS). A segurança foi avaliada por observação e relato de eventos adversos. Resultados: uma semana após a aplicação do preenchedor, foi observada melhora nos sulcos nasolabiais de 86% das mulheres e nos lábios de 89% delas. Reação inflamatória, transitória, leve ou moderada e equimoses ocorreram em 15% e 9% das pacientes, respectivamente, sobretudo nos sulcos nasolabiais. Duas pacientes apresentaram herpes simples labial após o tratamento dos lábios. Os bons resultados se mantiveram em 76% e 57% das mulheres, nos sulcos nasolabiais e em 72% e 45% delas nos lábios, após três e seis meses, respectivamente. Conclusão: o preenchedor Perfectha® mostrou-se eficaz e seguro para essas indicações.

Introduction: The use of dermal filling techniques for soft tissue augmentation has greatly increased in recent years.Hyaluronic acid is one of the most used temporary dermal fillers in the treatment of facial wrinkles, furrows, and folds due to its effectiveness and safety. Objective: To evaluate the efficacy and safety of Perfectha®, a new hyaluronic acid filler, for nasolabial folds and lip correction. Methods: Open, multicenter study comprising 87 women. Efficacy was evaluated by the Global Aesthetic Improvement Scale and the Wrinkle Severity Rating Scale. Safety was evaluated through observation and the reporting of side effects. Results: One week after the injection of the filler, improvement in nasolabial folds and lips was observed in 86% and 89% of the women, respectively. Mild or moderate transient inflammatory reaction and ecchymoses occurred in 15% and 9% of patients, respectively, mainly in nasolabial folds. Two patients presented labial herpes simplex after treatment of the lips.The good results were maintained in 76% and 57% of women for nasolabial folds and in 72% and 45% of women for lips after 3 and 6 months, respectively. Conclusion: Perfectha® was effective and safe for these indications.

Estudo comparativo da aplicação de CRMDex® em igual volume em uma versus duas sessões para correção dos sulcos nasogenianos / CRMDex® in the treatment of nasolabial folds: a comparative study of same applied in one versus two sessions

Introdução: O interesse por procedimentos minimamente invasivos para o rejuvenescimento facial proporcionou o desenvolvimento da técnica de preenchimento cutâneo para rugas e sulcos.O ácido hialurônico é um dos preenchedores mais populares, considerado menos imunogênico e mais seguro.Objetivos: avaliar e comparar a eficácia, segurança e duração do efeito da aplicação do preenchedor CRMDex® nos sulcos nasogenianos, em sessão única e em duas sessões. Métodos: ensaio clínico, aberto, com randomização dos sulcos nasogenianos e comparativo entre duas técnicas.Trinta mulheres, de 30 e 60 anos de idade, com acentuação simé-trica dos sulcos nasogenianos de grau leve a moderado foram submetidas à aplicação intradémica de CRMDex®.Três dermatologistas independentes avaliaram a eficácia utilizando a escala Wrinkles Severity Rating Scaling.Resultados: o tratamento realizado em duas sessões não se diferenciou do realizado em uma sessão, pois ambos proporcionaram diminuição de pelo menos um grau na escala Wrinkles Severity Rating Scaling com similar duração do efeito preenchedor. Os efeitos adversos locais mais frequentes (dor, eritema e edema) ocorreram durante a injeção emelhoraram espontaneamente. Conclusões: não houve otimização da resposta terapêutica com a injeção de volumes menores por sessão. Parece que volumes maiores podem aumentar o risco de efeitos adversos locais.

5-Fluorouracil superficial peel for multiple actinic keratoses.

BACKGROUND: Chronically photodamaged skin usually presents with multiple, widespread, actinic keratoses (AKs), and treatment of the entire affected area is recommended. METHODS: We report our experience with a combination of Jessner's solution or 70% glycolic acid (GA) with 5% 5-fluorouracil (5-FU) solution for superficial pulse peeling used in the treatment of widespread AKs in 31 patients. Pulse peelings were performed at biweekly intervals. The endpoint for treatment was complete or maximum clearance of the lesions at clinical evaluation. Pre- and post-skin biopsy and histopathologic examination were performed in three patients for the purpose of demonstrating the pulse peel effects. RESULTS: All patients achieved a satisfactory result, including the complete regression, or at least 80% clearing, of AK lesions and an overall improvement of photodamaged skin. CONCLUSION: We consider this superficial 5-FU pulse peel to be a safe, well-tolerated, very effective, and highly inexpensive therapeutic option for the treatment of multiple, diffuse AKs. Its benefit/cost ratio will be of interest to public health services, mainly in developing countries.

Aneurisma da artéria carótida externa: uma condição rara diagnosticada durante uma consulta cosmética / External carotid artery aneurysm: a rare condition diagnosed in cosmetic consultation

O objetivo deste relato é mostrar a importância e alertar os dermatologistas que praticam a cosmiatria sobre a necessidade de se realizar um exame completo e minucioso de qualquer paciente, mesmo que ele só esteja interessado em tratamentos e/ou procedimentos cosméticos. Atualmente, essa é uma preocupação importante, pois muitas pessoas e alguns médicos estão envolvidos em uma busca exagerada pela beleza eterna. Essa é uma prática muito lucrativa para dermatologistas e cirurgiões plásticos. No entanto, não devemos nos esquecer que uma consulta dermatológica pode ser uma oportunidade para diagnosticar uma dermatose que passou despercebida ou identifi car sinais relacionados a desordens sistêmicas.

The aim of this report is to highlight and warn cosmetic dermatologists about the need of a full body complete examination regardless of the complain of any patient that seeks our evaluation, even when they ask only for cosmetic treatments and/or procedures. This is nowadays a very important concern as people and some physicians are involved in an exaggerated search for eternal beauty. This represents a very profi table practice for dermatologists and plastic surgeons. But we should never forget that a dermatologic consultation can be an opportunity to discover an unnoticed dermatosis or signs related to systemic diseases.

Transgrediens pachydermodactyly: report of a case.

Pachydermodactyly is a rare form of digital fibromatosis involving the proximal portions of the fingers that usually affects young males. We present a 25-year-old male patient with a two year history of asymptomatic nodules in the fingers. Three months before the visit, he had observed similar lesions on the feet and right knee. Histopathological analysis showed thickened dermis with proliferation of fibroblasts and collagenous fibers, with deposition of mucinous material. This represents a rare case of pachydermodactyly of transgrediens form.

Paquidermodactilia transgressiva: relato de um caso / Transgrediens pachydermodactyly: report of a case

A paquidermodactilia é forma rara de fibromatose digital envolvendo as porções proximais dos dedos, que afeta homens jovens. Apresenta-se caso de paciente de 25 anos com quadro de nódulos assintomáticos nas mãos há dois anos, e há três meses com lesões semelhantes nos pés e no joelho direito. O exame histopatológico revelou espessamento da derme com proliferação de fibroblastos e de fibras colágenas e aumento de mucina. O caso descrito corresponde à paquidermodactilia do tipo transgressiva.

Pachydermodactyly is a rare form of digital fibromatosis involving the proximal portions of the fingers that usually affects young males. We present a 25-year-old male patient with a twoyear history of asymptomatic nodules in the fingers. Three months before the visit, he had observed similar lesions on the feet and right knee. Histopathological analysis showed thickened dermis with proliferation of fibroblasts and collagenous fibers, with deposition of mucinous material. This represents a rare case of pachydermodactyly of transgrediens form.

Eficácia e tolerabilidade de uma nova toxina botulínica tipo a para tratamento estético de rugas faciais dinâmicas: estudo multicêntrico prospectivo de fase III / Efficacy and Tolerability of a New Botulinum Toxin Type A for Cosmetic Treatment of Dynamic Facial Wrinkles: a Prospective, Phase III, Multicenter Study

Introdução: A toxina botulínica é opção importante para o tratamento das rugas faciais dinâmicas. A toxina botulínica Lanzhou tipo A (LBTX-A) foi introduzida na China no início da década de 1990 e aprovada no Brasil em 2003. Objetivo: Avaliar a efi cácia e a tolerabilidade de LBTX-A para tratamento estético de rugas dinâmicas na parte superior da face. Materiais e Métodos: Em um estudo multicêntrico prospectivo com rótulo aberto, 110 indivíduos dos dois gêneros (idades de 25 a 65 anos) foram tratados com um total de 53 U de LBTX-A cada, distribuídos em 15 locais nos músculos frontal, corrugador, prócero e lateral ocular da órbita. Os pacientes foram revisados sete vezes no intervalo de 180 dias. A efi cácia foi avaliada por eletromiografi a, análise fotográfi ca e pelas opiniões do investigador e do paciente. A tolerabilidade foi avaliada pela incidência de eventos adversos. Resultados: Duas semanas depois das injeções, 94% dos pacientes tratados consideraram o resultado bom ou excelente. Na maioria dos casos, os resultados se prolongaram por 90 dias. Depois da injeção, quase todos os pacientes informaram dor leve ou ausência de dor e efeitos colaterais mínimos e reversíveis, como edema facial (seis pacientes), sensação de entumescimento facial (três pacientes) e ptose palpebral (dois pacientes). Conclusões: LBTX-A é efi ciente e bem tolerado para tratamento das linhas faciais dinâmicas.

Introduction: The botulinum toxin is a valuable option for the treatment of dynamic facial wrinkles. The Lanzhou botulinum toxin type A (LBTX-A) was introduced in China in the early 90's and approved in Brazil in 2003. Objective: Evaluate the effi cacy and tolerability of LBTX-A for the cosmetic treatment of dynamic wrinkles of the upper face. Material and Methods: In a prospective, open-label, multicenter study, 110 subjects of both sexes (aged from 25 to 65 years) were treated with a total of 53 U of LBTX-A each, distributed in fi fteen sites in the frontal, corrugator, procerus, orbicular ocular lateral muscles. The patients were reviewed 7 times within 180 days. Effi cacy was assessed by electromyography, photographic analysis and the investigator's and patient's opinions. Tolerability was assessed by the incidence of adverse events. Results: Two weeks post-injection, 94% of the treated patients considered the result as good or excellent. Results lasted 90 days in most cases. After injection, most patients reported mild or no pain, and minimal and reversible side effects as facial edema (6 patients), stuffi ness feeling (3 patients) and eyelid ptosis (2 patients). Conclusions: We conclude that LBTX-A is effi cient and well tolerated for the treatment of dynamic facial lines.