A 37-year-old woman was referred to the study with the complaints of active rosacea with no previous treatment. She did not present any type of injury or inflammation, burns at the site, poor healing, diabetes, presence of skin cancers, warts, herpes, skin infection, pregnancy, the habit of using sunscreen daily, or treatment with acute or chronic corticotherapy. On dermatological examination, the patient presented Fitzpatrick skin phototype I, mixed lubrication, opened pores in the nasal region, normal (smooth) keratinization, presence of erythematoustelangiectatic rosacea with telangiectasias on the cheeks, cheekbones and nose under an undefined erythema, reporting a burning sensation during episodes of facial flushing. Clinical erythema assessment (CEA) determined a score 2, which means a rosacea with mild erythema and a defined redness. Besides, the quality of life of patients with rosacea by the RosaQol [5] indicated a total score of 81 (the minimum value of the questionnaire score is 21 and the maximum is 105, being the higher the score, the worse the quality of life).
The patient received 2 sessions (1 hour duration each) of the treatment with fifteen days of intervals. The skin cleaning was done with chlorhexidine 0,12%. 100 UI of botulinum toxin type A (incobotuninumtoxinA, Xeomin®, Merz Pharmaceuticals, Frankfurt, Germany) was diluted in 4 ml of saline solution 0,9% and applied topically directly to the skin, only in the area affected by rosacea [6]. In sequence, the nonthermal microneedling procedure was performed sliding over the face regions (Figure 1). The gliding microneedling machine (Smart Derma pen®, Smart GR, Lisbon, Portugal) was adjusted to the third vibration speed, with a 36-needle cartridge and puncture 0.5 mm of the skin, performing rectilinear and circular directions four times in each quadrant of the affected area. After the procedure, 2 ml of serum was applied. After 2 sessions, no side effects were seen.
Forty-five days after the first sessions of treatment, the telangiectasias in the malar region became less apparent and there was a reduction in erythema in the same place (Figure 2a and 2b). The same also occurred in the nasal region. The participant reported less burning sensation during episodes of facial redness (flushing). In general, the aspect of the skin showed a more uniform tone (Figure 2). The RosaQol score was 35 and the CEA indicated score 1 (almost clear skin; slight redness). Written consent was obtained from the patient for publication of this case report and any accompanying images.