Objective: To describe a previously unreported case of bilateral hemifacial spasm after acne vulgaris treatment inducing hypocalcemia.

Background: A 33-year-old female with no medical history was referred to neurology for facial twitching. She complained of bilateral painless twitching of her lower face when applying makeup in the area. Six months prior, she saw her dermatologist for acne, who recommended limiting dairy consumption to treat acne, which she followed religiously for 3 months until symptoms started. She takes no medications.

Method: On exam, vitals were stable. She had no spontaneous muscle activity or abnormal movement when she activated the facial nerve. However, tapping of either side 2cm anterior to the tragus and 2cm below the zygomatic bone elicited ipsilateral facial nerve activation of the risorius, zygomaticus, levator labii, in essence, the Chovstek’s sign.

Results: Lab work was notable for calcium level of 8.5 mg/dL (normal 8.5-10.2) and 25-hydroxy vitamin D level of 10 (normal 20-50 ng/mL). MRI Brain and MRA head FIESTA sequence revealed no compression of the facial nerve. Patient was prescribed vitamin D and Calcium 500 U daily supplementation and had rapid improvement to her symptoms.

Conclusion: We report a 33-year-old female who presented with bilateral facial spasm in the setting of hypocalcemia secondary to low dairy consumption for treatment of acne. A clinical manifestation of hypocalcemia is Chvostek’s sign, while tapping of the facial nerve above the masseter results in ipsilateral facial spasm due to CN7 tetany. Calcium level can be normal in 50% of cases. Normally this is only seen in parathyroid issues and post operative complications. Sign would not have been diagnosed unless elicited appropriately. Decreasing dairy is a common recommendation for acne patients due to whey protein in dairy. In patients who are counseled to decrease dairy, providers and patients should be familiar with consequences of hypoglycemia, check Calcium and Vitamin D levels and determine the need for prophylactic supplementation.

References: 1. Baldwin H, Tan J. Effects of diet on acne and its response to treatment. Am J Clin Dermatol. 2021;22(1):55-65.
2. Kamalanathan, S. Balachandran, K. Parthan, G. Chvostek’s Sign: A Video Demonstration. BMJ Case Rep. 2012: 10.1136/bcr-2012-007098
3. Turner, J. Gittoes, N, Selby, P. et al. Society for Endocrinology Endocrine Emergency Guidance. Endocr Connect. 2016; 5(5): G7-G8.

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