Adjunct botulinum toxin for cicatricial pemphigoid

Cicatricial changes secondary to conjunctivitis associated with pemphigoid can include subconjunctival fibrosis, forniceal shortening, symblepharon with resultant entropion and trichiasis. This can ultimately lead to limbal stem cell deficiency and irreversible corneal keratopathy. Herein, we present a case series of three patients at a single academic institution between 2022 and 2024 that underwent botulinum toxin-A injection for lower eyelid cicatricial entropion as a temporizing treatment due to active cicatrizing conjunctivitis. All patients reported subjective improvement in ocular irritation following injection. All patients demonstrated improvement in their eyelid margin position with decreased orbicularis override and improved anterior trajectory of lashes. No patient experienced exacerbation of their pemphigoid and all patients opted for serial injections (mean of 4.3 treatments). This series demonstrates that botulinum toxin-A is an effective tool in the limited armamentum of treatment options for patients with cicatrizing entropion during phases of active cicatrizing conjunctivitis when more definitive conjunctival incisional surgeries are contraindicated.