eMedicine Specialties > Dermatology > Surgical

Botulinum Toxin: Follow-up

Author: Zoltan Trizna, MD, PhD, Private Practice
Contributor Information and Disclosures

Updated: Feb 20, 2009

Outcome and Prognosis

The effects of botulinum toxin injections are not immediately noticeable. The full effect is achieved approximately 3-7 days after treatment, with the peak at around 1 month. The results last for about 4-6 months with a gradual reappearance of the wrinkles.

The results are cumulative; repeated treatments tend to lead to longer-lasting effects. After several injections of botulinum toxin into the same anatomic region, the underlying muscles may become atrophied. This effect usually leads to the permanent resolution of the wrinkles.

For comparison, the patient's face should be photographed before treatment and at follow-up visits.

In the treatment of hyperhidrosis, the use of botulinum toxin results in dramatic improvement, which can be objectively documented by repeating the starch-iodine test. The treatment must be repeated every 4-6 months.

Botulinum toxin treatment of hyperhidrosis in persons with social anxiety disorder has led to improvement of social functioning and a reduction of overall disability.13

Future and Controversies

Future

In addition to the treatment of glabellar lines, the number of FDA-approved indications for the use of botulinum toxin in cosmetic applications may increase.

The treatment of wrinkles with botulinum toxin is becoming more popular, and demand for it is expected to increase. The cosmetic use of botulinum toxin is essentially controlled by market forces because most health insurance does not cover it. Economic trends (especially trends in the amounts of disposable income) and social issues influence the number of people seeking treatment. Also, the limited number of products and suppliers affect the current prices of the treatment.

Controversies

What conditions should be treated with injections of botulinum toxin? Generally, treatment of the glabellar, frontal, and temporal frown lines is considered safe. Several authorities consider other uses around the mouth and on the neck risky.

Which preparation should be used? Each preparation is unique, and the products are not necessarily interchangeable. Different botulinum toxin serotypes significantly differ in their relative potencies and durations of action that affect the clinical outcome. Even different preparations of the same serotype can have marked differences. For instance, 1 U of BOTOX® has a potency that is approximately equal to 4 U of Dysport. From a clinical point of view, these preparations may be used interchangeably with appropriate dosage adjustments. However, the current data are insufficient to determine whether one product is superior to another.14

Both products have advantages and disadvantages. BOTOX® (Allergan) has been widely used in the United States and Canada for more than a decade. Its safety is well established. The drawback is that once the contents of a vial are dissolved, the reconstituted product loses its potency. Therefore, dermatologists tend to schedule the treatments for several patients on the same day so that they can use the entire contents of the vial. This scheduling may be inconvenient for some patients, who may decide not to proceed.

Myobloc (Elan), when reconstituted, has a shelf life of more than 12 months. This feature is advantageous in terms of patient scheduling. However, larger volumes of Myobloc may be needed to obtain effects similar to those of BOTOX®. Antibody formation against this product may occur more often because of its higher protein content.

Studies with botulinum toxin type B (Myobloc, Neurobloc) showed safety and efficacy in the treatment of axillary hyperhidrosis.15,16

Comparative studies of BOTOX ®, Dysport, and Myobloc are relatively rare. A 2007 review analyzed these products in patients with cervical dystonia. Differences were noted in the rates of adverse events.17 Another study found that Dysport had a greater area of diffusion than BOTOX ®.18

 


More on Botulinum Toxin

Overview: Botulinum Toxin
Workup: Botulinum Toxin
Treatment: Botulinum Toxin
Follow-up: Botulinum Toxin
References
[ CLOSE WINDOW ]

References

  1. Berman B, Seeberger L, Kumar R. Long-term safety, efficacy, dosing, and development of resistance with botulinum toxin type B in cervical dystonia. Mov Disord. Feb 2005;20(2):233-7. [Medline].

  2. Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol. Jan 1992;18(1):17-21. [Medline].

  3. Macdonald MR, Spiegel JH, Raven RB, Kabaker SS, Maas CS. An anatomical approach to glabellar rhytids. Arch Otolaryngol Head Neck Surg. Dec 1998;124(12):1315-20. [Medline].

  4. Matarasso A, Matarasso SL, Brandt FS, Bellman B. Botulinum A exotoxin for the management of platysma bands. Plast Reconstr Surg. Feb 1999;103(2):645-52; discussion 653-5. [Medline].

  5. Farrugia MK, Nicholls EA. Intradermal botulinum A toxin injection for axillary hyperhydrosis. J Pediatr Surg. Oct 2005;40(10):1668-9. [Medline].

  6. Heckmann M, Ceballos-Baumann AO, Plewig G. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med. Feb 15 2001;344(7):488-93. [Medline].

  7. Naver H, Swartling C, Aquilonius SM. Palmar and axillary hyperhidrosis treated with botulinum toxin: one-year clinical follow-up. Eur J Neurol. Jan 2000;7(1):55-62. [Medline].

  8. Schulte-Mattler WJ, Wieser T, Zierz S. Treatment of tension-type headache with botulinum toxin: a pilot study. Eur J Med Res. May 26 1999;4(5):183-6. [Medline].

  9. Matarasso SL, Matarasso A. Treatment guidelines for botulinum toxin type A for the periocular region and a report on partial upper lip ptosis following injections to the lateral canthal rhytids. Plast Reconstr Surg. Jul 2001;108(1):208-14; discussion 215-7. [Medline].

  10. Smith ME, Ford CN. Resistance to botulinum toxin injections for spasmodic dysphonia. Arch Otolaryngol Head Neck Surg. Apr 2000;126(4):533-5. [Medline].

  11. Latimer PR, Hodgkins PR, Vakalis AN, Butler RE, Evans AR, Zaki GA. Necrotising fasciitis as a complication of botulinum toxin injection. Eye. 1998;12 ( Pt 1):51-3. [Medline].

  12. Chertow DS, Tan ET, Maslanka SE, et al. Botulism in 4 adults following cosmetic injections with an unlicensed, highly concentrated botulinum preparation. JAMA. Nov 22 2006;296(20):2476-9. [Medline].

  13. Connor KM, Cook JL, Davidson JR. Botulinum toxin treatment of social anxiety disorder with hyperhidrosis: a placebo-controlled double-blind trial. J Clin Psychiatry. Jan 2006;67(1):30-6. [Medline].

  14. Odergren T, Hjaltason H, Kaakkola S, et al. A double blind, randomised, parallel group study to investigate the dose equivalence of Dysport and Botox in the treatment of cervical dystonia. J Neurol Neurosurg Psychiatry. Jan 1998;64(1):6-12. [Medline].

  15. Baumann L, Slezinger A, Halem M, et al. Pilot study of the safety and efficacy of Myobloc (botulinum toxin type B) for treatment of axillary hyperhidrosis. Int J Dermatol. May 2005;44(5):418-24. [Medline].

  16. Nelson L, Bachoo P, Holmes J. Botulinum toxin type B: a new therapy for axillary hyperhidrosis. Br J Plast Surg. Mar 2005;58(2):228-32. [Medline].

  17. Chapman MA, Barron R, Tanis DC, Gill CE, Charles PD. Comparison of botulinum neurotoxin preparations for the treatment of cervical dystonia. Clin Ther. Jul 2007;29(7):1325-37. [Medline].

  18. Trindade de Almeida AR, Marques E, de Almeida J, Cunha T, Boraso R. Pilot study comparing the diffusion of two formulations of botulinum toxin type A in patients with forehead hyperhidrosis. Dermatol Surg. Jan 2007;33(1 Spec No.):S37-43. [Medline].

  19. Annese V, Bassotti G, Coccia G, et al. Comparison of two different formulations of botulinum toxin A for the treatment of oesophageal achalasia. The Gismad Achalasia Study Group. Aliment Pharmacol Ther. Oct 1999;13(10):1347-50. [Medline].

  20. Aoki KR. Pharmacology and immunology of botulinum toxin serotypes. J Neurol. Apr 2001;248 Suppl 1:3-10. [Medline].

  21. Armstrong MW, Mountain RE, Murray JA. Treatment of facial synkinesis and facial asymmetry with botulinum toxin type A following facial nerve palsy. Clin Otolaryngol Allied Sci. Feb 1996;21(1):15-20. [Medline].

  22. Bigalke H, Wohlfarth K, Irmer A, Dengler R. Botulinum A toxin: Dysport improvement of biological availability. Exp Neurol. Mar 2001;168(1):162-70. [Medline].

  23. Braune C, Erbguth F, Birklein F. Dose thresholds and duration of the local anhidrotic effect of botulinum toxin injections: measured by sudometry. Br J Dermatol. Jan 2001;144(1):111-7. [Medline].

  24. Brin MF. Botulinum toxin: chemistry, pharmacology, toxicity, and immunology. Muscle Nerve Suppl. 1997;6:S146-68. [Medline].

  25. Huang W, Foster JA, Rogachefsky AS. Pharmacology of botulinum toxin. J Am Acad Dermatol. Aug 2000;43(2 Pt 1):249-59. [Medline].

  26. Lowe NJ. Botulinum toxin type A for facial rejuvenation. United States and United Kingdom perspectives. Dermatol Surg. Nov 1998;24(11):1216-8. [Medline].

  27. Matarasso SL. Complications of botulinum A exotoxin for hyperfunctional lines. Dermatol Surg. Nov 1998;24(11):1249-54. [Medline].

  28. Naumann M. Evidence-based medicine: botulinum toxin in focal hyperhidrosis. J Neurol. Apr 2001;248 Suppl 1:31-3. [Medline].

  29. Naumann M, Jankovic J. Safety of botulinum toxin type A: a systematic review and meta-analysis. Curr Med Res Opin. Jul 2004;20(7):981-90. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

botulinum toxin, botulinum toxin type A, botulinum toxin type B, BOTOX®, BOTOX, Myobloc, Elan, Neurobloc, Dysport, Clostridium botulinum, C botulinum, botulism, wrinkles, crow's feet, frown lines, bunny lines

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Zoltan Trizna, MD, PhD, Private Practice
Zoltan Trizna, MD, PhD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Désirée Ratner, MD, Director of Dermatologic Surgery, Professor of Clinical Dermatology, Department of Dermatology, Columbia University Medical Center, New York Presbyterian Hospital
Désirée Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Mary Farley, MD, Dermatologic Surgeon/Mohs Surgeon, Anne Arundel Surgery Center
Disclosure: Nothing to disclose.

CME Editor

Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University
Catherine Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.