On this page we discuss Botox’s origin story, how it works and some of its uses. If you are interested in Botox treatment at Anue, please go to our treatment page.
Botulinum toxin A (BoNT-A) is a protein produced by a bacterium called Clostridium botulinum which is one of the most effective treatments to improve the signs of aging.
While its first medical use was to help with vision, it is now a widely used treatment in medicine. Common uses include fine lines & wrinkles, muscle spasms, migraines, and even hyperhidrosis (excessive sweating).
Botox® is the first widely-used brand of botulinum toxin and is still the most commonly used. The development of new molecules such as Dysport® and Xeomin® has made it more affordable and improved some aspects of treatment.
History of Botulinum Toxin
In the late 1700s and early 1800s, botulinum toxin was called prussic acid and sausage poison due to its ability to cause botulism. The earliest documented outbreak of this was in 1793 in Wildbad, southern Germany. Dr. Justinus Kerner published his monograph on ‘sausage poison’ in 1822.1Schantz EJ, Johnson EA. Botulinum toxin: the story of its development for the treatment of human disease. Perspect Biol Med. 1997;40(3):317-327. doi:10.1353/pbm.1997.0032,2Carruthers A, Carruthers J, Ibrahim O. Procedures in Cosmetic Dermatology: Botulinum Toxin. Elsevier Health Sciences; 2023.
It wasn’t until 1895 that bacteriologist Professor Émile Pierre-Marie van Ermengem successfully identified the bacterium Clostridium botulinum as the causative agent when he was researching another outbreak in a small Belgian village.3Erbguth, F. From poison to remedy: the chequered history of botulinum toxin. J Neural Transm 115, 559–565 (2008). doi:10.1007/s00702-007-0728-2
In the mid-1900s, Dr. Alan Scott began to conduct early research on botulinum toxin (BoNT-A). This culminated in a landmark 1980 article, describing BoNT-A’s amazing therapeutic effects for visual disturbances when used in small doses.4Scott AB. Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. J Pediatr Ophthalmol Strabismus. 1980;17(1):21-25. doi:10.3928/0191-3913-19800101-06,5Scott AB. Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. Ophthalmology. 1980;87(10):1044-1049. doi:10.1016/s0161-6420(80)35127-0. After further research established its safety, the US Food and Drug Administration (FDA) in 1989 approved the initial uses of BoNT-A for the treatment of eye disorders such as strabismus (cross eyes), blepharospasm (involuntary movement of the eyelids), hemifacial spasm, and Meige syndrome.6Coté TR, Mohan AK, Polder JA, Walton MK, Braun MM. Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases. J Am Acad Dermatol. 2005;53(3):407-415. doi:10.1016/j.jaad.2005.06.011,7Carruthers A, Carruthers J, Ibrahim O. Procedures in Cosmetic Dermatology: Botulinum Toxin. Elsevier Health Sciences; 2023.
Allergan acquired Dr. Scott’s company in 2002 and renamed the brand from Occulinum to Botox. Since then, the use of Botox has exploded for numerous indications in both medical and cosmetic medicine. There are over 7 million BoNT-A procedures performed each year in numerous countries around the world.
Development of Alternatives
Dysport, a slightly different version of BoNT-A was approved by the FDA in 2002. In 2009, Xeomin was first approved for cosmetic use, followed by the approval of Jeuveaux in 2011.
In 2023, the FDA approved Daxxify (DaxibotulinumtoxinA) for cosmetic uses.8Mussarat A, Mustafa MS, Azam ST, Nafees Uddin MM, Nasrullah RMU, Siddiq MA. DAXI (DaxibotulinumtoxinA) – An Innovative Approach for Frown Lines. Int J Gen Med. 2023 Apr 10;16:1267-1269. doi: 10.2147/IJGM.S406563.,9Carruthers A, Carruthers J, Ibrahim O. Procedures in Cosmetic Dermatology: Botulinum Toxin. Elsevier Health Sciences; 2023.
We discuss how these alternative types of botulinum toxin differ in their effects further down.
How does Botox work?
In the body, nerve cells (neurons) control the action of muscles by sending signals through different cells with the use of neurotransmitters. These are molecules that transmit signals through a network of nerve cells to muscles instructing them to contract and relax. There are several types of neurotransmitters, however, one of the most important is acetylcholine.
Botulinum toxin works by preventing the release of acetylcholine form neurons. This reduces nerve signaling, resulting in temporary muscle relaxation. This property of the toxin makes it useful for treating medical conditions such as muscle spasms, dystonia, chronic migraines, and excessive sweating (hyperhidrosis).
Of course, this property is highly desired for for cosmetic applications, such as smoothing wrinkles, by temporarily relaxing facial muscles. It is by far the most common treatment in aesthetic medicine for numerous indications such as frown lines, crow’s feet, forehead wrinkles.
Is Botox safe?
Millions of people have benefited from the therapeutic effects of BoNT-A over the last fifty years. It has been studied extensively in numerous clinical trials which have overwhelmingly demonstrated its short- and long-term safety, when used appropriately.
Of course, any medication or procedure can have side effects. Most of the short-term side effects are related to the physical injection rather than the medication. These include pain, bleeding, bruising, redness (erythema), tenderness, swelling, and headache. These short-term effects can be minimised with good injection technique by more experienced and skilled injectors.
Rarely, the medication can diffuse into adjacent muscles, which can affect talking and swallowing. Allergies to BoNT are rare, however, those who do have an allergy to BoNT or any components of the product should avoid its use. Dysport (AbobotulinumtoxinA) should not be used in those with cow’s milk protein allergies. Singers and wind instrument musicians should avoid peri-oral injections so that their music is not adversely affected.
People with neuromuscular junction disorders such as Lambert-Eaton syndrome and myasthenia gravis have traditionally been advised to avoid treatment with BoNT. However, recently, doctors have started treated them, provided they are carefully managed.10Ma Q, Ran H, Ou C, et al. Is myasthenia gravis a contraindication for botulinum toxin? J Clin Neurosci. 2022;95:44-47. doi:10.1016/j.jocn.2021.11.010 Like most treatments that penetrate the skin, injections should be avoided in sites of active infection or inflammation.
BoNT-A has not been studied well enough in pregnant or nursing women and has been classified as pregnancy category C. It’s best to avoid unless necessary.
Some medications can increase the effect of BoNT-A including gentamicin, clindamycin, and penicillamine. Others can reduce the effect of BoNT-A such as chloroquine and hydroxychloroquine. It is important that your injector knows what medications you are taking, so that they can safely adjust the dosage and administration of BoNT-A.
How is Botox administered?
Botulinum toxin A normally comes as a powder that is reconstituted into a solution with the addition of a liquid. Several different liquids are used to reconstitute BoNT-A. Originally, preservative-free saline was used.
However, recently, preserved saline which contains benzyl alcohol is becoming more popular. This has anti-bacterial and anaesthetic properties, improving safety and comfort for people. Allergic reactions to benzyl alcohol are rare.11Lorenc ZP, Kenkel JM, Fagien S, et al. Consensus panel’s assessment and recommendations on the use of 3 botulinum toxin type A products in facial aesthetics. Aesthet Surg J. 2013;33(1 Suppl):35S-40S. doi:10.1177/1090820X13480479
Your treatment provider will carefully plan the treatment locations and calculate the number of units to be injected. The number of units used varies depending on age, gender, size of the muscles, treatment region, and desired effect.
They will then inject the reconstituted BoNT into the muscles of the treatment area. A local anaesthetic is not typically used.
The treatment effect of Botox typically lasts for about four months.
***Hidden***However, Daxxify, a newer molecule has a duration of effect of around six months, although this comes with some potential downsides.
Common treatment sites
There are several BoNT treatment sites, the most common are:
- Glabella (between the eyebrows)
- Frontalis (horizontal forehead lines)
- Eyebrow shaping
- Crow’s feet (outer corner’s of eyes)
- Eyelids
- Neck
- Armpits (for excessive sweating)
Preventative Botulinum Toxin
Preventative BoNT injections are gaining popularity among those in their twenties and thirties. Even if wrinkles have already started to develop, repeated BoNT injections can help prevent them from getting worse. Several published studies support the use of preventative BoNT.12Binder WJ. Long-term effects of botulinum toxin type A (Botox) on facial lines: a comparison in identical twins. Arch Facial Plast Surg. 2006;8(6):426-431. doi:10.1001/archfaci.8.6.426,13Dailey RA, Philip A, Tardie G. Long-term treatment of glabellar rhytides using onabotulinumtoxina. Dermatol Surg. 2011;37(7):918-928. doi:10.1111/j.1524-4725.2011.02024.x,14Rivkin A, Binder WJ. Long-term effects of onabotulinumtoxinA on facial lines: a 19-year experience of identical twins. Dermatol Surg. 2015;41 Suppl 1:S64-S66. doi:10.1097/DSS.0000000000000193
The different brands of Botulinum Toxin
There are actually seven serotypes of botulinum toxin (named A-G). However, only subtypes of BoNT/A are used for cosmetic treatments. All these subtypes work in the same way, however, have slightly different properties.
As a result, these subtypes have different brands:
Botox
Botox (onabotulinumtoxinA) is the first brand of botulinum toxin used for cosmetic purposes and was the first of its kind to be approved by the FDA. It is the most studied form of botulinum toxin and is also approved to treat other conditions such as excessive sweating (hyperhidrosis), migraines, some joint issues, and more.
Onset of effect starts from 24-48 hours after administration, and can last for 3-4 months. Botox’s widespread acceptance, safety, and efficacy have made it a go-to choice for those looking for a minimally invasive, effective treatment.
Dysport
This form of botulinum toxin (abobotulinumtoxinA) generally has the fastest onset of its effects amongst all brands, which is why it has gained recent popularity. Most will start seeing results within 2-3 days. Dysport units are smaller, meaning more units are required to achieve the same treatment effect. However, due to the much lower unit cost, it tends to be more cost-effective.
Dysport can diffuse a little into adjacent areas, which can be helpful when treating large areas. As a result, some prefer this tendency to spread evenly, particularly for the forehead or the “eleven” lines.
Dysport produces very good results and many users feel it results in a more natural look.15 TR, Mohan AK, Polder JA, Walton MK, Braun MM. Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases. J Am Acad Dermatol. 2005;53(3):407-415. doi:10.1016/j.jaad.2005.06.011 Due to the slightly likely duration of effect (4-6 months), many recipients are satisfied with only two Dysport treatments per year.16Coté TR, Mohan AK, Polder JA, Walton MK, Braun MM. Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases. J Am Acad Dermatol. 2005;53(3):407-415. doi:10.1016/j.jaad.2005.06.011
Those with cow milk protein allergies should not use Dysport.
Xeomin
Normally, botulinum toxin A is a protein complex that is comprised of neurotoxin combined with protective complexing proteins. In contrast, Xeomin (incobotulinumtoxinA) is neurotoxin only without the complexing proteins. Theoretically, this was supposed to reduce the risk of developing neutralising antibodies and reactions to the medication. However, in reality some people still seem to develop antibodies.17Jost WH, Blümel J, Grafe S. Botulinum neurotoxin type A free of complexing proteins (XEOMIN) in focal dystonia. Drugs. 2007;67(5):669-683. doi:10.2165/00003495-200767050-00003,18Frevert J, Dressler D. Complexing proteins in botulinum toxin type A drugs: a help or a hindrance?. Biologics. 2010;4:325-332. Published 2010 Dec 9. doi:10.2147/BTT.S14902
Nonetheless, some people still prefer Xeomin as they feel it is a cleaner, more pure molecule.
| Botox | Dysport | Xeomin | |
|---|---|---|---|
| Ingredient | onabotulinumtoxinA | abobotulinumtoxinA | incobotulinumtoxinA |
| Onset (approx) | 7 days | 2-3 days | 5-7 days |
| Peak Action | 14 days | 14 days | 10-14 days |
| Duration | 4 months | 4-5 months | 3-4 months |
| Key Benefit | The original, most commonly used | Faster onset, more cost-effective | No additives |