Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2023;13(1):e2023032 1 Facial Bier Spots Unresponsive to Botulinum Toxin: A Case Series Pelin Esme1, Burcu Beksac1, Gulsen Akoglu1, Ercan Caliskan1 1 Department of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, Ankara, Turkey Key words: Bier spots, angiospastic macules, face, botulinum toxin Citation: Esme P, Beksac B, Akoglu G, Caliskan E. Facial Bier Spots Unresponsive to Botulinum Toxin: A Case Series. Dermatol Pract Concept. 2023;13(1):e2023032. DOI: https://doi.org/10.5826/dpc.1301a32 Accepted: June 9, 2022; Published: January 2023 Copyright: ©2023 Esme et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Pelin Eşme, MD, Department of Dermatology and Venereology, University of Health Sciences, Gulhane Training and Research Hospital, 06010, Kecioren, Ankara, Turkey, +9 0 312 304 44 67 Fax number: +9 0 312 304 27 00, pelinnesme@gmail.com Introduction Bier spots are asymptomatic, irregular anemic macules in a blanchable erythematous background. However, the patho- genesis is not clear yet; abnormal vasoconstriction of vessels has been suggested as the primary mechanism [1]. Lesions often involve extremities and the trunk; only one case with facial involvement has been reported previously [2]. Lesions do not require specific treatment, but patients may experi- ence cosmetic problems [3]. Herein, we described 3 cases with Bier spots on the face with accompanying tension-type headaches in all patients and tested the hypothesis that botulinum toxin might im- prove facial Bier spots. Case Presentation A 45-year-old male patient (Patient 1) was admitted to our outpatient dermatology clinic with a complaint of pale, whitish macules on the forehead. The complaints had started six months ago after trauma and become more visible with emotional stress and bending down. He also suffered from headaches and forehead wrinkles. A diagnosis of Bier spots was made upon clinical examination. Laboratory evalu- ations and imaging methods revealed no abnormalities. A total of 150 Speywood units (reconstituted with 2.5 ml normal saline) of botulinum toxin (AbobotulinumtoxinA, Dysport®, Ipsen, 500 units) were injected to forehead lines considering the localization of Bier spots (Figure 1). In addi- tion to cosmetic improvement of the frontal wrinkles within one week, headache severity regressed from 10 to 5 points according to the visual analog scale (VAS) for pain. Unfor- tunately, there was no response in Bier spots six weeks after botulinum toxin injection. The symptoms of a 48-year-old male patient (Patient 2) started one year ago on the trunk and face without any trig- gering (Figure 2). A 32-year-old female patient ( Patient 3) had experienced similar complaints on the forehead six months after her first vaginal delivery. Strikingly, both were accom- panied by tension-type headaches. Laboratory evaluations and imaging methods of both patients did not reveal any abnormality. 2 Research Letter | Dermatol Pract Concept. 2023;13(1):e2023032 Figure 1. Case 1. (A) Pretreatment. Bier spots were marked with black color to orient the injector. The hypopigmented macule highlighted with a red arrow was selected as a control area, and no injection was performed. (B) Post-treatment. Significant improvement was recorded in forehead lines at week 1, while there was no improvement in Bier spots. Figure 2. Case 2. The patient provoked these lesions by holding his breath for about a half minute and bending down just before the photographs. Research Letter | Dermatol Pract Concept. 2023;13(1):e2023032 3 Botulinum toxin injections were performed to Bier spots on the forehead of the patient 2, similar to Patient 1. While no improvement was observed in Bier spots at the end of the 6th week, the headache severity regressed from 10 to 2 points after one week according to the VAS score. Patient three recommended no treatment due to breastfeeding. Conclusions Recently, botulinum toxin in non-cosmetic medical con- ditions, including tension-type headaches, is becoming increasingly popular. Considering its effects on the cutane- ous vasculature [4-6], we aimed to test the hypothesis that botulinum toxin might relax the muscles around the small arterioles and increase transcutaneous blood flow, thereby reducing hypoxia and improving Bier spots. Possible com- mon pathogenesis for the coexistence of both diseases ap- pears to be genetic and triggering factors for an exaggerated vasoconstrictive response [1,6]. However, while tension-type headaches in both patients improved, Bier spots did not. Therefore, failure to botulinum toxin may be related to in- sufficient dosage or other unknown factors that play a role more critical than the exaggerated vasoconstrictive response. References 1. Fan Y-M, Yang Y-P, Li W, Li S-F. Bier spots: six case reports. 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