Botox For Beginners: What You Need To Know
Medically reviewed on Jul 11, 2018 by C. Fookes, BPharm.
What Is Botox? Isn't It Poisonous?
Many consider botulinum toxin to be the deadliest poison known to man. So how is it that we have come to inject it into our faces and many other areas of our body?
Even though ingestion of food contaminated with C. botulinum causes botulism - an often fatal, paralytic-type illness - when botulinum toxin is purified and injected in tiny, controlled doses it is very safe and effective at relaxing excessive muscle contraction.
Even though doctors as early as the 18th century suggested a possible medical use for the botulinum toxin, it took until the early 1970's before it was first used medically to treat strabismus - an abnormal alignment of the eyes.
How Does Botulinum Toxin Work?
There are eight different types of botulinum toxin produced by C. botulinum; A, B, C1, C2, D, E, F and G. All work by blocking the release of acetylcholine, one of the most significant neurotransmitters in our body. Acetylcholine activates muscles, so blocking it causes muscle relaxation and paralysis.
Injections enable the botulinum toxin to be targeted directly into specific muscles. There it has a direct effect on acetylcholine in the nerve synapses, preventing signals that would normally cause the muscle to contract.
Type A is the most potent and longest lasting, followed by types B and F. Currently, preparations containing Type A and B are commercially available. Effects are usually seen within 24-72 hours and peak around ten days. Effects last about two to three months or until new nerve terminals sprout and form new synaptic contacts.
Botulinum Toxin Products
There are several different botulinum toxin products available. All have different potencies and are not interchangeable; care needs to be taken that the correct dosage stated is used for that particular product. Approved indications also vary. Currently available products include:
What is Botulinum Toxin Used For?
Although cosmetic application of Botulinum toxins are the most well known, use of the neurotoxin has expanded to include almost every subspecialty of medicine, including:
- Chronic migraines that occur more than 15 days per month and last more than 4 hours each time
- Focal dystonias - involuntary muscle contractions in a specific body area (such as in the neck)
- Hemifacial spasm - involuntary twitching of muscles on one side of the face
- Hyperhidrosis - excessive sweating
- Hypersalivation - increased saliva
- Overactive bladder symptoms including incontinence when other medications are ineffective or not tolerated
- Strabismus - eye misalignment (one eye faces a different way to the other).
Cosmetic And Other Uses
Cosmetically, botulinum toxins smooth out lines, creases, and wrinkles on the face, chin, neck and chest. They temporarily improve the look of forehead lines, crow’s feet lines and frown lines between the eyebrows in adults.
Improvement is usually seen within 24 to 48 hours and effects can last up to 4 months. Several other types of spastic movement disorders and some other long-term conditions not effectively treated by other types of medical treatment also have reported success with botulinum toxins. The medical uses for botulinum toxins are likely to expand in the future.
Potential Side Effects
In rare instances, botulinum toxins have spread beyond the injection site and caused serious, potentially life-threatening side effects, such as difficulty swallowing or breathing, overall muscle weakness, blurred vision, drooping eyelids, and voice changes.
Children being treated for spasticity (muscle spasms) and people with certain underlying conditions are more at risk. Effects may occur hours to weeks after administration. Call emergency services if you experience any problems swallowing, speaking, or breathing soon after botulinum toxin administration or other symptoms indicating toxin spread, such as muscle weakness, vision changes, eyelid drooping, or loss of bladder control. Botulinum toxins should only ever be administered by a licensed provider for an FDA approved indication.
For the majority of people, side effects tend to be minor and restricted to the site of injection, and include complaints such as corneal dryness when used for blepharospasm, bleeding behind the eye when used for strabismus, and an increased incidence of colds or other upper respiratory tract infections.
Can Resistance Develop To Botox-Like Preparations?
Botulinum toxins are a type of protein. As with any protein, antibodies can potentially develop with repeated exposure, because the body views it as an antigen, activating the immune response. Once formed, these antibodies block the effects of the botulinum toxin, neutralizing its action.
Most case reports concern onabotulinumtoxinA, the first botulinum toxin to be marketed. In 1997, the original formulation was changed to reduce the protein load per dose, and since then treatment failure rates have dropped; however, experts estimate 0.3 to 6% of people are still at risk of antibody development. The risk is greatest when dosages of more than 200 units per session are used, and reinjection occurs within one month. Experts are unsure if neutralizing antibodies resolve over time or if injections of botulinum toxin type B products are useful in patients with neutralizing antibodies to type A.
Products Are Not Interchangeable: Potency Varies Considerably
It is important to remember that the three types of botulinum toxin type A preparations available in the U.S.: abobotulinumtoxinA [Dysport], incobotulinumtoxinA [Xeomin], and onabotulinumtoxinA [Botox, Botox Cosmetic]), and one botulinum toxin type B preparation (rimabotulinumtoxinB [Myobloc]) are NOT interchangeable.
Each individual manufacturer uses assay methods specific to their company, so even though dosages may be quoted in similar sounding units, potency varies several fold between the different products.
How Are Botulinum Toxin Products Given?
A thin needle is used to inject botulinum toxin into affected muscles or glands. Dosages vary depending on the size of the muscle (larger muscles require higher dosages), who is being injected (some females may require lower dosages), and the presence of pre-existing muscle weakness. Electromyography may be used to guide injection in delicate areas.
Rest and avoidance of strenuous activity are advised as a general precaution after each appointment to minimize toxins dislodging and traveling due to increased blood circulation. In addition, laser/IPL treatments, facials, and facial massage should be avoided for one to two weeks after injections.
Finished: Botox For Beginners: What You Need To Know
- Erbguth FJ. Historical notes on botulism, Clostridium botulinum, botulinum toxin, and the idea of the therapeutic use of the toxin. Mov Disord. 2004 Mar;19 Suppl 8:S2-6. http://www.ncbi.nlm.nih.gov/pubmed/15027048
- Erbguth FJ. From poison to remedy: the chequered history of botulinum toxin. J Neural Transm (Vienna). 2008;115(4):559-65. Epub 2007 Apr 26. http://www.ncbi.nlm.nih.gov/pubmed/17458494
- Foodborne Illness. Common Bacteria and Viruses that Cause Food Poisoning. http://www.foodborneillness.com/botulism_food_poisoning/
- Botox Cosmetic. What Should I Expect With Treatment? http://www.botoxcosmetic.com/Why-Botox-Cosmetic#what-to-expect
- Nigam PK, Nigam A. Botulimium toxin. Indian J Dermatol. 2010 Jan-Mar; 55(1): 8–14. doi: 10.4103/0019-5154.60343. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856357/
- Botox.com. http://www.botox.com/
- Botox FDA Prescribing Information. Drugs.com. https://www.drugs.com/pro/botox.html
- Torres S, Hamilton M, Sanches E, et al. Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine: five case reports. Clin Cosmet Investig Dermatol. 2014; 7: 11–17. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3872090/