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General Rehabilitation

A Rare Case of Pruritus Post-Botulinum Toxin Injection

Saturday, October 25, 2025
12:00 PM - 1:30 PM MT
Location: Kiosk 1
Has Audio

    Poster Presenter(s)

  • AS

    Ayah Syeed, Other

    Medical Student
    Ohio University Heritage College of Osteopathic Medicine
    Herndon, Virginia

  • Ameer Qadri, M4

    Medical Student
    Midwestern University: Chicago College of Osteopathic Medicine
    Naperville, Illinois

    • Co-Author(s)

  • SD

    Shashank Dave, DO

    Associate Professor
    Indiana University School of Medicine PM&R Program
    Zionsville, Indiana

Disclosure(s):
Ameer Qadri, M4: No financial relationships to disclose
Shashank Dave, DO: No financial relationships to disclose
Case Diagnosis: Pruritus Post Botulinum Toxin Injection

Case Description or Program Description: An 81-year-old female with a past medical history of a right basal ganglia hemorrhagic stroke, hypertension, GI bleed, and seasonal allergies was seen in our outpatient PM&R clinic for spasticity management. She had functionally limiting spasticity in her arm and leg, which hadn’t responded to oral anti-spasticity medications. She kept up with her home exercise program she learned in therapy. She received botulinum toxin type A injections in various muscles in the left upper and lower extremities, which managed her spasticity well, and helped improve both passive and active function.

Setting: Outpatient

Assessment/Results: She received this treatment every 3 months for 4 years and was tolerating the injections well up until 2 years ago, when she began complaining of one week of severe generalized itching after each injection. The only documented medication allergy was cephalexin. The pruritus was initially thought to be due to the skin preparation used (chlorhexidine plus alcohol), so only alcohol was used to clean her skin at her next appointment. She still experienced one week of itching post injection. Diphenhydramine was then started for one week and her usual dose of loratadine was held; this controlled her pruritus successfully. She has tolerated subsequent botulinum toxin injections well with this regimen; she currently receives 1 week of diphenhydramine 25mg twice a day after each botulinum toxin injection.

Discussion (relevance): It is postulated that this patient developed a hypersensitivity to the toxin itself, or to a components, such as an excipient, causing mast cell activation. This case highlights the importance of staying vigilant about possible adverse effects of botulinum toxin administration, even if the patient had tolerated injections for years in the past.

Conclusions: To our knowledge, this is the first documented case report of severe generalized pruritus following botulinum toxin administration treated successfully with oral diphenhydramine.