Long-term Cosmetic Use of Botulinum Toxin Type A

In the United States, the cosmetic use of botulinum toxin type A (BTX-A) has continued to grow over the last 15 years, according to multispecialty data recently released by the American Society for Aesthetic Plastic Surgery. During these years, many of our patients, if not ourselves, have undergone treatment faithfully every 3 to 6 months to combat the signs of aging. Subsequently, with the monitoring of adverse events (AEs), the US Food and Drug Administration has issued a black box warning that covers serious side effects—respiratory compromise and death—associated with treatment, yet most of what is listed in the black box warning pertains to medical use rather than cosmetic use. However, with the ever-growing indications for BTX-A, we must be cognizant of the fact that our patients may be receiving concomitant treatment with BTX-A for medical conditions (eg, migraines, hyperhidrosis, achalasia, dysphonia, dystonia, strabismus) by other specialists. Thus, there is a need to understand the potential side effects associated with BTX-A treatments and long-term consequences.

In a January 21 article published online in Pharmacology Yiannakopoulou looked at national monitoring programs through the US Food and Drug Administration and the Danish Medicines Agency. Many of the AEs reported were related to medical use of BTX-A, including anaphylaxis, death, generalized weakness, and dysphagia. Serious AEs related to the cosmetic use of BTX-A included thyroid eye disease, sarcoidal granuloma, pseudoaneurysm of the frontal branch of the superior temporal artery, and severe respiratory failure. Additionally, a patient receiving BTX-A for palmar and axillary hyperhidrosis developed botulinumlike generalized weakness. Upon review of epidemiological studies, the incidence and types of AEs were covered. The vast majority of these events were related to the medical use of BTX-A, which could stem from the lack of long-term studies on cosmetic patients and the lack of reporting of many AEs. The author summarized that minimizing potential AEs relies on proper injection technique, proper storage of the medication, proper dosing, and thorough knowledge of the anatomy.

What’s the issue?

Botulinum toxin type A remains one of the most gratifying treatments for both physicians and patients alike. However, with the potential for abuse, as in the case of the recent fake Botox Cosmetic that has shown up on the market in the United States), we must remain vigilant for AEs. Furthermore, we must continue to emphasize to patients that it is a medical treatment and deserves all the attention and respect we give to other medical interventions. However, as the Yiannakopoulou review has shown, proper injection techniques have a low rate of AEs in the cosmetic use of BTX-A. Have you seen an increase in the number of cosmetic BTX-A patients receiving concomitant treatments with BTX-A for medical conditions? If so, how do you manage them?

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