The boom in botulinum toxins

Evolving growth expands choices and success.

Young Black female patient gets botulinum toxin injection.

Botulinum toxin use has advanced significantly since its introduction in aesthetics more than 20 years ago. Today, there are multiple choices of botulinum neurotoxin type A (BNTA) products with evolving indications and uses. A quick look at the history of BNTA products and the future of the clinical use of neuromodulators was the focus of the March 10 session, F081 – Botulinum Toxins: The Latest Updates.

Session director and Miami dermatologist Joely Kaufman, MD, FAAD, presented attendees with current data on the similarities and differences for available and soon-to-be-available drugs as well as repeated dosing and their influences on outcome.

“Mitchell Brin, MD, covered the history of neuromodulators, including the original discovery of improvement of wrinkles while injecting patients for strabismus,” Dr. Kaufman said. “In fact, many current indications for our neuromodulators were born from observations while treating medical patients in both neurology and ophthalmology.”

The session featured discussions by dermatologists who have been innovators of botulinum toxins and involved at every stage of development of the neurotoxin market. They included Jean D.A. Carruthers, MD, Mitchell Brin MD, Andre Vieira Braz, MD, and Doris M. Hexsel, MD, IFAAD.

Dr. Carruthers outlined the possibilities of reversal agents for botulinum toxin, including a new acetylcholinesterase inhibitor that could potentially help treat complications from botulinum toxins. 

Dr. Kaufman presented updates on new nueormodulators that could be on the market in the U.S. soon. In fact, one new toxin, letibotulinum toxinA, was just approved a few days prior to the AAD Annual Meeting in San Diego. Other new formulations include liquid formulations, relabotulinum toxinA and nivobotulinum toxinA as well as a quick onset (complete onset within 24 hours), short acting (less than 30 days), type E botulinum toxin (BNTE). 

Determining ideal injection locations and anatomic safety zones is crucial in achieving successful outcomes with neuromodulator treatments, Dr. Braz said. He outlined the anatomy of the musculature to show where to inject and where to avoid for optimal outcomes and safety. 

The U.S. now has six approved toxins with multiple indications and more to come, since the original approval of onabotulinum toxin for glabellar lines in 2000.

“Each neuromodulator has its own ‘flavor’ and although they may be similar in mode of action, they are each unique in manufacturing, reconstitution, onset, duration, field of effect, and even price,” Dr. Kaufman said. “This allows the physician to have choices for their patients and allows us to customize treatments for each individual’s desired outcome.”

A look at current neuromodulators

Screen Shot 2024 04 23 At 1 54 21 PmOnabotulinum toxinA was the first botulinum toxin approved by the FDA in 2000 for use in facial aesthetic procedures in the United States. This neurotoxin is used to temporarily smooth frown lines (wrinkles between the eyebrows) in adults 18 years of age and older, smooth crow’s feet lines (wrinkles near the outer corner of the eye) in adults 18 years of age and older, and to smooth forehead lines in adults 18 years of age and older.

Abobotulinum toxinA is used to smooth facial lines and crow’s feet as well as smooth wrinkles in the neck. It inhibits release of acetylcholine at the neuromuscular junction. Injection of small quantities of botulinum toxin into specific overactive muscles causes localized muscle relaxation that smooths the overlying skin and reduces wrinkles. It is contraindicated in persons with keloidal scarring, neuromuscular disorders (e.g., myasthenia gravis), allergies to constituents of botulinum toxin products, and body dysmorphic disorder. 

Incobotulinum toxinA is used to treat glabellar frown lines, crow’s feet, mimic lines, and hyperkinetic facial lines. It is also used to decrease drooling.

Prabotulinum toxinA is used to treat facial wrinkles and is safe and effective for the treatment of moderate-to-severe glabellar lines in adults.

Daxibotulinum toxinA is used for the improvement in the appearance of moderate-to-severe glabellar lines associated with corrugator and/or procerus muscle activity of glabellar lines.

Letibotulinum toxinA recently received FDA approval and is one of the most popular cosmetic procedures worldwide. It is used for the treatment of glabellar lines.