In the past few years botulinum toxin has transformed the treatment of aging skin. Thanks to this simple, non-invasive procedure, it is no longer necessary to undergo a major operation and a prolonged recovery period to effectively reverse the signs of aging. Today, botulinum toxin is being administered to successfully manage a variety of dermatologic conditions as well as being used to restore the youthful glow.

Botulinum Toxin: What Is It?

Botulinum toxin is a purified form of one of the most potent poisons in the world. In high doses, it can cause the clinical disease botulism. However, when carefully injected by dermatologists and dermatologic surgeons in very low doses, botulinum toxin is a modern tool that can reduce the signs of aging and alleviate aches and pains.

In nature, botulinum toxin is formed and released by the bacteria Clostridium botulinum. In its natural form it is the cause of botulism food poisoning. Botulinum toxin blocks nerve signals transmitted from the brain to the muscle, causing paralysis of the injected muscle. It works locally by inhibiting the release of acetylcholine, a neurotransmitter, from the nerve.

Medicine modified the potent neurotoxic effects of botulinum toxin for the treatment of medical conditions. For example:

• In two studies, botulinum toxin was reported effective in treating migraine headaches. In one study, patients reported a reduction in the frequency of migraine headaches, vomiting, and the use of pain medications after a one-time dose of 25 units of botulinum toxin was injected into the muscles of the brow, forehead and side of the head. In another study of 96 patients, 51 percent reported complete improvement of overall migraine pain.
• A recent study of botulinum toxin used in relief of lower back pain was reported in the May 2001 issue of the journal Neurology. After three weeks of botulinum toxin treatment, 11 of 15 patients reported more than 50 percent relief of pain.
• Injecting botulinum toxin into sweat glands can correct some cases of hyperhidrosis (excessive sweating) from the palms of the hands, soles of the feet, and armpits.
• Injecting botulinum toxin into muscles around the eye can correct some cases of blepharospasm, a spasm of the eyelids that makes a person involuntarily blink constantly.
• Injecting botulinum toxin into eye muscles can correct some cases of strabismus, a deviation or "squint" of one or both eyes that cannot be corrected with eyeglasses or behavioral training.

Dermatologists have adapted very low doses of botulinum toxin for the treatment of crow’s feet around the eyes, frown lines in the forehead and brow, lines around the nose, and folds in the neck. Botulinum toxin quickly proved to be a very safe and effective method of facial skin rejuvenation, with results that last three to six months.

In combination with other facial skin rejuvenation procedures such as chemical peeling, dermabrasion, soft-tissue augmentation and laser skin resurfacing, botulinum toxin can improve post-procedure results by preventing the reappearance of wrinkles in the resurfaced skin. Used prior to a skin rejuvenation procedure, botulinum toxin can relax muscles and create a smoother, level surface for the procedure.

Where is Botulinum Toxin Used in Skin Rejuvenation?

Botulinum toxin is injected into target muscles to get the desired effect of muscle relaxation and subsequent "smoothing out" of the skin under the muscle’s control. The muscles selected for injection are those associated with the skin defects the patient wishes to have eliminated:

Click on The Brow (wrinkles and frown lines) and The Forehead (horizontal lines) to view some before-and-after photos that show dramatically the effects of botulinum toxin. Photos from the collection of Harold Brody, M.D.

How Long Does Botulinum Toxin Treatment Last?

The muscle-relaxing effects of botulinum toxin are noticeable in a week or less after treatment. The cosmetic improvement lasts three to six months. As the temporary relaxing effect of botulinum toxin subsides, muscle tone returns and treatment needs to be repeated. Patients who have repeated treatments may eventually notice that muscles stay relaxed for longer periods of time between treatments.

What Are the Side Effects of Botulinum Toxin?

Botulinum toxin treatments have been found to have few side effects that the patient might find unpleasant or that might be regarded as harmful. There may be temporary bruising around an injection site. Very rarely a patient may notice temporary weakness in a muscle next to an injection site.

The changes in botulinum toxin-injected muscle are temporary and reversible. A possible positive side effect is the lessening of migraine and tension headache reported by some patients who received botulinum toxin injections into forehead muscles.

How Long Does It Take for a Botulinum Toxin Treatment?

Most botulinum toxin treatments are completed in 30-minutes or less. The treatment should be preceded by a medical and physical examination to make certain the patient is a good candidate for treatment. Botulinum toxin injections are done by a dermatologist or dermatologic surgeon in the office or outpatient setting. The patient is able to leave immediately and resume normal daily activities. Follow-up visits are recommended to check on maintenance of muscle relaxation and timing of re-treatment after three to six months.

Who Gives Botulinum Toxin Treatments?

Dermatologists and dermatologic surgeons trained and experienced in the procedure are the best choice to give botulinum toxin treatments. Click on Choosing a Dermatologist for information about dermatologists, dermatologic surgeons and their qualifications. Link to American Society for Dermatologic Surgery for more information about the procedure and about dermatologic surgeons.

More and Future Uses of Botulinum Toxin in Medicine

Botulinum toxin is proving useful in many ways where relaxation of muscle relieves symptoms or treats a disease. New and investigative uses of botulinum toxin include treatment of:

• anal and vaginal muscle spasm;
• laryngeal spasm;
• low-back muscle spasm;
• torticollis ("wry neck");
• hand tremor;
• achalasia (spasm of the gastrointestinal tract); and,
• muscle spasms that may occur as complications after a stroke.

Botulinum toxin is a safe and effective muscle-relaxing agent. Future uses of botulinum toxin will develop in coming years. Its recent use for the treatment of migraine headaches and lower back pain is a good example of the broadening usage of botulinum toxin.

References

Dermatologic Insights, Spring 2001, P. 25.

ASDS brochure "Botulinum Toxin Treatment."

Klein AW. Substances for soft tissue augmentation. In: Freedberg IM et al (Eds.) Fitzpatrick’s Dermatology in General Medicine, 5^th ed. New York: McGraw-Hill; 1999:2969-2971.

Foster L et al. Botulinum toxin A and chronic low back pain: a randomized, double-blind study. Neurology 2001; 56:1290-1293.

Yin S et al. Clinical applications of botulinum toxin in otolaryngology. Head and neck practice. J La State Med Soc 2001; 153:92-97.

Whatling PJ et al. Botulinum toxin injection is an effective treatment for axillary hyperhidrosis. Br J Surg 2001; 88:814-815.

Bruley dVS et al. Current trends in the management of achalasia. Dig Liver Dis 2001; 33:266-277.

Brin MF et al. A randomized, double masked, controlled trial of botulinum toxin type A in essential hand tremor. Neurology 2001; 56:1523-1528.