Is there More Than One Type of Toxin (Btx)?

 - Dr. Liz Kelleher, drliz@lkaesthetics.com, (021) 484-3444

Not many people know that there are FOUR different types of btxA type drugs available and FDA approved for use in the United States and Europe.
The four btxA products are as follows:

1) Botox by Allergan
2) Myobloc by Solstice Neurosciences
3) Dysport by Ipsen, Ltd (Now owned by Valeant Pharmaceuticals)
4) Xeomin by Merz

Just to add further confusion, these drugs are called by different names in the UK/Ireland. Botox is Vistabel. Dysport is Azzalure. Xeomin is Bocouture. Myobloc is Neurobloc. For simplicity I will use the FDA labeled names in this blog.

Botox by Allergan was the first and most popular to the point where its product name "botox" is being used interchangeably to mean any botulinum toxin product; much like "Hoover" is used to mean any vaccuum cleaner or "Google" to mean "to search for" even if you use Yahoo.

In addition Johnson & Johnson, another powerful company with a competitive product is due to enter the market in the next few years.

Botox is made by Allergan and has 85% of the market share while Dysport & Xeomin have 15% share of the Cosmetic Btx market. Currently, Myobloc has approval for therapeutic use only.

Johnson and Johnson are seeking approval for their new drug next year and are expected to shake up the market significantly. They have the budget, the sales force and they already sell dermal fillers into the market.

Although all four products are made from the Clostridium botulinum bacteria, the four products are isolated from different strains of bacteria, have different molecular structures, and attach to different parts of the nerve. What does this mean for the end-user? It means that dosages are not equivalent across product lines. In other words, 1 unit of botox is NOT the same as 1 unit of myobloc. Furthermore, duration of effect may be different as well as immune response. Also as an FYI, Botox, Xeomin, and Dysport are Botulinum toxin type A whereas Myobloc is type B.

So, What is the difference between Botox, Dysport and Xeomin? and Which is the best one?

Botox is a leading cosmetic treatment that drastically reduces the appearance of crow’s feet, lines on the forehead and frown lines. With US FDA approval and launch of this revolutionary anti-aging product in 1989, millions continue to turn to Botox over 20 years later as part of their aesthetic regimen for looking younger.

However,the two newer products are having great success, Dysport (approved for cosmetic use in Europe in 2001, US FDA approved 2009) and Xeomin (approved for cosmetic use in Europe in 2005, US FDA approved 2011).

All three are effective treatments that originate from the same source bacterium, clostridium botulinum. They are synthesized as botulinum toxin type A, the paralyzing agent or neurotoxin that is administered. Each has been consistently proven in clinical trials and then worldwide application. The result is almost always the same. Each injectable temporarily paralyzes the targeted muscle areas on the face to relax and ease out the appearance of wrinkles. Because of their proven abilities, each is often paired with a dermal filler like Restylane or Sculptra that results in dramatic facial rejuvenation. This procedure is known as a liquid facelift.

Xeomin is a purified neurotoxin. It is referred to as a ‘naked’ molecule because there are no additive surface proteins, just the botulinum toxin. This solitary agent migrates further and faster to effectively work upon all facial areas upon injection. There is less risk of an allergic reaction or rejection for the client from the absence of protein additives. In addition, Xeomin does not need to be refrigerated.

In comparison, Botox and Dysport are considered ‘heavier’ because they contain added proteins. These proteins are for protection and are clustered around the botulinum to enable them to last a little longer. However, the clinical argument is that these protective proteins may also shield the active part of the neurotoxin thereby minimizing product effectiveness.

One of the noted benefits of Dysport is that it spreads a little more than Botox and it is commonly used by patients who have stopped responding to Botox. It is also injected at a different strength and affects a slightly larger area than Botox and Xeomin. It has been reported that Dysport typically takes two to three days until the effects of the treatment are seen. Botox takes seven to ten days while Xeomin takes five to six days. Dysport may be the best option in areas where several injections are needed because of its easy spreading to cover a greater area on the face. In the areas where the spread needs to be minimized, Botox may be the best option to concentrate on deeper wrinkling. Over time with different Botox, Dysport and Xeomin injections, clients begin to favor which treatment works best for them.

Botox and Xeomin, have exactly the same units, are reconstituted and administered in exactly the same way, and take effect in the same amount of time, which makes it relatively easy for a practice that uses Botox to add or switch to Xeomin. Because everything about the treatment process is identical, Botox and Xeomin prices can be compared directly. The difference between Xeomin and Botox is that the Botox molecule is stabilized with a protein "wrapper" while the Xeomin molecule is "naked". The smaller Xeomin molecule is less likely to stimulate the development of antibodies. However, only about 1 in 10,000 Botox patients develop these antibodies so a small reduction in this rate is not significant.

Dysport has different units than Botox and Xeomin, it is reconstituted differently, and it takes effect one to three days faster. The injection amounts and techniques are different for the same treatment areas, which makes it more difficult for a practice that uses Botox or Xeomin to add or switch to Dysport. It also makes it more difficult to compare prices.

There are a number of questions that have received a lot of attention and some disagreement:

    Should I be worried that Dysport and Xeomin are newer products?

    Not at all because neither Dysport nor Xeomin are new. Dysport has been used in fifteen European countries since 1990 and Xeomin has been used in over twenty countries since 2010.

    Which medication takes effect faster?

    In clinical studies, the effects of Dysport consistently took effect one to three days faster than Botox or Xeomin.

    Which medication lasts longer?

    Clinical studies have shown very slight variations in each of the medications but recent studies have concluded that the longevity of all three products is the same. Some researchers have reported that clinical results with Dysport last longer than Botox (4-7 months as compared with 3-6 months) and that results with Dysport are often noticed a day or two earlier than with its competitor Botox (2-4 days as compared with 3--8 days). There are also reports documenting that Dysport improves the appearance of crow's feet significantly better than Botox. This is ascribed to the property of Dysport to diffuse better. Xeomin seems to act more like Botox than Dysport. It is observed that it takes about one week for the full effects of Xeomin injections to be realized, and once this occurs, the results seem to last from 3-6 months.

    What is the difference between a unit of Botox, a unit of Xeomin, and a unit of Dysport?

    Botox and Xeomin units are identical. Depending on the area being treated, between two and three units of Dysport are equivalent to one unit of Botox or Xeomin. Since the conversions are not the same for all treatment areas, you cannot directly compare units between Dysport and the other two medications.

    Does Dysport have a greater diffusion ratio than Botox or Xeomin?

    The diffusion ratio is another way of saying how fast and how far the medications spread out from the injection points. This is important because, if the medication spreads out too far, it will affect muscles that were not the target of the treatment. When this occurs, it can cause temporary eyelid droop (ptosis), lowering of the lip, or facial asymmetry. Botox, Dysport, and Xeomin are distributed as tiny amounts of medication that must be reconstituted and diluted, usually with nonpreserved normal saline solution. The manufacturers provide recommended dilution amounts and Dysport recommends about three times more dilution than Botox or Xeomin. This means that three times as much liquid volume is injected for a Dysport treatment than for the same Botox or Xeomin treatment. The greater volume means that Dysport has a greater chance of diffusing into muscles not targeted by the treatment. However, the experience and technique of the doctor performing the injection is much more important. Also, clinical trials in which a lower Dysport dilution was used (2.5:1 instead of 3:1) produced no significant difference in diffusion ratios between Dysport, Botox, and Xeomin.

    Can Botox, Dysport, and Xeomin treat the same areas?

    Because of the greater dilution of Dysport, LK Aesthetics does not recommend it for treating fine lines around the mouth or bunny lines near the eyelids. There are reports documenting that Dysport improves the appearance of crow's feet significantly better than Botox. This is ascribed to the property of Dysport to diffuse better.  Any of the medications can be used for the forehead, glabellar (between the eyebrows), and periorbital (crow's feet) areas. Excessive underarm sweating (hyperhidrosis) can be treated with Botox but Dysport and Xeomin are not currently used for that purpose.

    Should there be price differences for the same treatment areas?

    When Dysport was initially released, the recommended dilutions made Dysport about 10% less costly than Botox. However, many practices found that a higher concentration of Dysport was needed to achieve the same results as Botox and this made the prices nearly identical. Xeomin has always been priced identically to Botox. LK Aesthetics has the same price for Dysport and Botox treatments. This allows you and Dr. Kelleher  to decide between the medications based on a medical examination and a discussion of your own preference and experience, rather than on price.