Are you developing resistance to Botox?
Since the pandemic and the issuance of the COVID-19 vaccine, there have been a lot of chatter around Botox resistance. At alarmingly higher rates, patients have been reporting that their results are disappearing in shorter time-frames, with some even reporting no change in aesthetic appearance at all. So what is the science behind Botox resistance and how can your injector prevent this from happening to you?
For decades, Botulinum toxin (BoNT) has been used for a myriad of aesthetic and medical outcomes. There exists two serotypes: type A and type B that are current approved for clinical use, and while considered safe and effective, their use had been seldom complicated and affected by the development of antibodies. For the ease of understanding, we’ll break down the information into the structure of BoNT as it relates to immunogenicity, primary and secondary non-responders.
Botulinum toxin structure and antibodies
BoNT is made up of a core neurotoxin and associated non-toxic proteins. These non-toxic proteins prevent degradation of the core neurotoxin. Different BoNT types have varying non-toxic protein structures. Xeomin, or Incobotulinumtoxin A, is the only product where all the associated non-toxic proteins have been removed.
Antibodies against BoNT can be divided into: 1) Those targeting the core neurotoxin and 2) Those targeting the accessory non-toxic proteins. The latter antibodies do not pose a threat to aesthetic outcome or product efficacy.
Studies have shown that immune response also varies by product:
Botox: 0.2-3.6%
Dysport: 2.5%
Xeomin 0-0.5%
Primary Non-responders
This refers to a situation or event where the patient who received BoNT fails to have any outcome from their very first injection and from all subsequent treatments. Although some patients may identify themselves as having this, studies have shown that it is actually quite rare, with some estimating that true non-responders are seen in <2% of the population.
There are several factors to consider when one believes they are a primary non-responder:
Is the dosage too low?
Was it injected into the correct muscle?
Was the product properly stored?
Is there a true indication for BoNT?
Does the patient have a prior vaccination against BoNT?*
* Vaccinations against serotypes A-E were used in around 8000 US military personnel during the Gulf War
Secondary Non-responders
This refers to a patient having had an initial aesthetic outcome or benefit but began to experience a loss of response with subsequent treatments. This is further defined as experiencing no response after at least 2 consecutive treatments.
Because BoNT injections introduce a foreign protein that essentially acts as an antigen, the formation and production of antibodies also occurs as a result. However studies have shown that poor or no response has been commonly due to:
Insufficient dosing
Inappropriate muscle selection
Injections into the wrong muscle or structure
The prevlance of Botox ‘boosters’
Shorter time period between treatments
What can be done to prevent and address Botox non-response:
Although the research surrounding Botox resistance is still quite fresh, the consensus of ways to mitigate Botox non-responders have been uniform. Here are ways you and your injector can prevent resistance:
Determine the lowest dose possible that will still achieve your desired outcome
Switching from products that contain accessory proteins to Xeomin (the only product at this time without accessory proteins)
Alternating product choice at each treatment
Sticking with the recommended treatment intervals
Avoiding frequent injection "boosters”
Taking a break from Botox all together to allow for clearance of antibodies
