Aesthetic Dermatology MCQ - Management of Rhytids

A 50-year-old woman with Fitzpatrick skin type III presents with moderate to severe dynamic glabellar rhytides. She has a history of migraines and is seeking a non-surgical treatment option. Management of Rhytids

9/16/20252 min read

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A 50-year-old woman with Fitzpatrick skin type III presents with moderate to severe dynamic glabellar rhytides. She has a history of migraines and is seeking a non-surgical treatment option. Which of the following is the most appropriate first-line treatment?

A) OnabotulinumtoxinA (Botox)
B) Ablative fractional carbon dioxide laser
C) Hyaluronic acid filler injection
D) Topical tretinoin 0.1% cream
E) Chemical peel with trichloroacetic acid (TCA)

Correct Answer: A) OnabotulinumtoxinA (Botox)

Explanation

This patient presents with dynamic glabellar rhytides ( frown lines), which are caused by repeated contraction of the corrugator and procerus muscles. The history of migraines is also a key factor, as onabotulinumtoxinA is approved for both cosmetic use and migraine prevention.

First-Line Treatment: Neuromodulators (OnabotulinumtoxinA)

  • Mechanism: OnabotulinumtoxinA (Botox) works by inhibiting the release of acetylcholine at the neuromuscular junction, causing temporary chemodenervation and muscle relaxation. This smooths existing dynamic rhytides and prevents the formation of new ones.

  • Indication: It is the first-line treatment for dynamic facial rhytides, including glabellar lines, forehead lines, and crow's feet.

  • Additional Benefit: The patient's history of migraines is significant because onabotulinumtoxinA is FDA-approved for chronic migraine prevention. This treatment can address both concerns simultaneously.

  • Procedure: Precise intramuscular injection into the corrugator and procerus muscles. Effects last 3-4 months.

Why Not the Other Options?

  • (B) Ablative fractional carbon dioxide laser: This is excellent for textural improvement and static rhytides (lines present at rest) caused by photodamage and collagen loss. It is not first-line for dynamic lines and requires downtime.

  • (C) Hyaluronic acid filler injection: Fillers are ideal for static rhytides and volume loss (e.g., nasolabial folds). They do not address muscle movement causing dynamic lines.

  • (D) Topical tretinoin 0.1% cream: A retinoid that improves fine wrinkles via collagen stimulation and epidermal thickening over months. It has minimal effect on deep dynamic lines.

  • (E) Chemical peel with trichloroacetic acid (TCA): Improves superficial to medium-depth static rhytides and dyspigmentation. It does not affect muscle-induced dynamic rhytides.

Combination Therapy:
For comprehensive rejuvenation, especially if static rhytides are also present:

  • Neuromodulator (for dynamic lines) + filler (for volume loss) + laser/resurfacing (for texture) is a common approach.

Prognosis:
Excellent for dynamic rhytides with neuromodulators. The dual benefit for migraines is a significant advantage in this case.

Note: Always assess whether rhytides are dynamic (with movement) or static (at rest). Neuromodulators are the cornerstone for dynamic lines. The patient's medical history (migraines) further supports the use of onabotulinumtoxinA, making it a therapeutic and cosmetic choice.