I’ve had a number of patients ask me recently about natural injections for wrinkles, they’ve heard of clinics offering a product that is supposed to be a more natural form of, or the ‘purist’ form of botox- aka cleaner or safer than regular botox. Given the way these clinics are advertising “we use only the purist form of neuromodulators”, it is easy to see how patients would assume this means it’s a better product for you, assume they would be getting a healthier version of the treatment, and in turn, want to get their injections done at that clinic. Don’t succumb to misleading advertising! Yes there are differences between the various products available for wrinkle-relaxing, but these differences do not equate to one being healthier or more natural than the others. So this months blog is all about dispelling natural botox myths, breaking down basics of botox, the differences between the products on the market and what these differences really mean for the consumer.
BOTOX IS JUST A BRAND
Everyone refers to it as getting ‘botox’, but it’s time to correct your lingo, there are actually 4 types of wrinkle-relaxing preparations commercially available for dermatological application in Canada, and Botox is just one of them: OnabotulinumtoxinA marketed as BOTOX®/BOTOX® Cosmetic, abobotulinumtoxinA as Dysport®, incobotulinumtoxinA as Xeomin®, prabotulinumtoxinA as Jeuveau®. Collectively, these drugs are known as neuromodulators. Botox was the first on the market, so much like Kleenex is to tissue, Botox is often inappropriately used to describe all botunlinum toxin A (BoNTA) therapy. So now that you’re in the know, I’ll be using the correct terms for anti-wrinkle injections – neuromodulators or BoNTA.
BOTULINUM TOXIN A BASICS
Botulinum toxin is the product of a bacteria Clostridium botulinum. It is a neurotoxin that inhibits the release of the neurotransmitter acetylcholine at the neuromuscular junction resulting in flaccid paralysis (weakening) of the affected muscles. There are seven serologically distinct types of botulinum toxin that exist: A, B, C1, D, E, F, and G. The different types have different molecular sizes, degrees of activation, and mechanisms of action. What you need to know is that the pharmaceutical world uses botulinum toxin type A (BoNTA). Botulinum toxin was first used in the treatment of eye muscle disorders, but researchers soon noticed the appearance of frown lines improved in patients being injected, thus the wrinkle-relaxing and cosmetic effects of botulinum toxin were discovered.
Botox is manufactured by the company Allergan, Dysport by Galderma, Xeomin by Mertz, and the newest player Jeuveau by Evolus. Despite minor differences, they are all botulinum toxin A neurotoxins. It’s important to understand this because as the demand for natural, clean skin care continues to rise, more and more skin clinics are advertising clean injections with natural or pure neuromodulators, and this can be incredibly misleading to the consumer.
CUT THE CLEAN TALK
So where is all this clean talk coming from? It stems from the differences between the additives used in commercial preparation. Botox contains BoNTA complex (botulinum toxin A with complexing protein structure), human serum albumin (a protein found in human blood) and sodium chloride (salt). Dysport contains BoNTA complex, human serum albumin and lactose monohydrate (sugar from dairy). Xeomin, often advertised as the purist neuromodulator on the market, contains BoNTA complex-free, human serum albumin (the highest amount of all of the brands), and sucrose (plant sugar). Finally, Jeuveau contains BoNTA complex, human serum albumin and sodium chloride.
Let’s summarize. All 4 products contain botulinum toxin A and a derivative of human blood in varying amounts. Botox and Jeuveau are made with salt, while Xeomin and Dysport are made with sugar. Dysport contains a sugar derived from dairy so the only major caveat to safety is patients with a dairy allergy, they should not be using Dysport. Pretty straight forward so far…
So here’s where we get to the misleading. All of the products contain BoNTA attached to a complexing protein in varying size except Xeomin, The BoNTA in xeomin has been purified from complexing proteins. Does this mean it is a cleaner, superior, or more safe product? No. What are complexing proteins anway? Mostly, they are negligible. Complexing proteins do not play a role in the mechanism of action of neuromodulators. Complexing proteins do not equate to more adverse health effects or complications, but they may play a role in stimulating immunologic activity against the therapeutic agent, meaning they may be a factor in why someone might develop a resistance or tolerance to the product. Xeomin then, can be said to be the least likely of the 4 preparations to develop a tolerance to. But, because it has been purified of these complexing proteins, it is the purest form of botox on the market. See how that can be misconstrued?
HOW DO INJECTORS PICK THE PRODUCTS THEY USE?
injectors develop relationships with the companies they order from, they may have learned to inject using a particular product, they may get better product pricing from a particular company, or through clinical experience/outcomes, develop a preference. As an injector, I do see differences in outcomes between the products, despite the fact that they are all versions of the same thing. Generally speaking, I find Dysport is more potent and tends to last the longest, so I use this product most frequently in my clinic. It means my patients require less units and get more longevity from their treatment (3-4 months). This is NOT always the case, I have patients that prefer the feel/look/longevity of injections for wrinklesBotox and many patients that respond better to Xeomin. I have not yet tried Jeuveau but given the fact that it contains BoNTA, something tells me it’s going to work! All of the products are effective at reducing the appearance of wrinkles, so what’s more important than the type of product being used is the skill, attention to safety and artistry of the injector.
Having a thorough consultation with an experienced injector will determine if these types of injections are safe and indicated for you, and what product might best suit.
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You might also want to read our previous blog, Your Guide To Pre-Wedding Skin Care Treatments
- Allergan. Botox Monograph, 2014.//allergan-web-cdn-prod.azureedge.net/allergancanadaspecialty/allergancanadaspecialty/media/actavis-canada-specialty/en/products/pms/botox-pm-2014-07-07_e.pdf
- Evolus. Jeuveau Monograph, 2019. //www.accessdata.fda.gov/drugsatfda_docs/label/2019/761085s000lbl.pdf
- Frevert, J & Dressier D. Complexing proteins in botulinum toxin type A drugs: a help or a hindrance? 2010. //www.ncbi.nlm.nih.gov/pmc/articles/PMC3010823/
- Galderma. Dysport Monograph, 2017. //www.galdermaconnexion.ca/sites/default/files/media/Dysport-aesthetic-pm-Jan%203_17.pdf
- Zoltan, T.Dermatologic Use of Botulinum Toxin. 2019.//emedicine.medscape.com/article/1126453-overview
Merz. Xeomin Monograph, 2013.//www.merzcanada.com/files/Xeomin%20Product%20Monograph%20June%202013.pdf