{'fraction_non_alphanumeric': 0.02776572668112798, 'fraction_numerical': 0.018655097613882864, 'mean_word_length': 4.852791878172589, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Botulinum Toxin Injection: A Novel Treatment for Erosive Vulvitis.

A 68-year-old-woman presented to the dermatology clinic, complaining of erythematous and erosive lesions on her vulva for 3 months, associated with severe pain and burning sensation preventing normal daily activities (sitting, washing, going to the toilet, and normal sexual function). She does not have any previous medical history except for recurrent lower urinary tract infections. She was previously treated with topical creams such as silver sulfadiazine and clobetasol propionate 0.05% as well as 40mg per day of oral prednisone for 1 month and intralesional triamcinolone with poor tolerance to local therapy and no success. Physical examination showed significant bilateral swelling, erythema, and erosion over the inner side of her labia minora. The area was very tender and showed hypertonic contracted pelvic floor muscles on palpation (Figure 1). A previous incisional biopsy revealed erosive lichen planus of the vulva. The patient was prescribed methotrexate starting with 7.5 mg/wk for 6 weeks then 10 mg/wk for 16 weeks, without any improvement. As an adjunct and after providing informed consent, 20units of onabotulinum toxin A ([Botox, Allergan, Irvine, CA] [BTX]) was injected in the eroded mucosa of the vestibule on each side, at the submucosal level. Two weeks later, pain and burning sensation significantly decreased from 10/10 to 3/10 on a numeric pain scale. Dermatology Life Quality Index (DLQI) also decreased from 30 to 13. Physical examination revealed a significant reduction in erythema and inflammation of the vulva (Figure 2). She was prescribed 10 mg of methotrexate per day along with topical clobetasol ointment. Two months later, her pain arose again. She was reinjected with 30 units of BTX at the same point on each side and a dose escalation of themethotrexatewas planned starting the week after the visit. The patient did not increase the dose andpreferred towait for the injection to take effect. She started to improve 2 weeks after treatment and great recovery was observed 1 month after treatment (Figure 3); DLQI was reduced to 8 and numeric pain scale to 2/10. No adverse events were noted. She remained symptom free for next 3 months. She is expected to return to the clinic next month.