In my 15 years as a beauty editor, I’ve had more than a few people tell me they feel like their neurotoxin injections aren’t working anymore. “Can you become immune to it?” asked a friend. A reader asked me on Instagram if I had heard of “botox resistance.” Although not common, it is possible. For some people, their line-smoothing neurotoxin (Botox Cosmetic, Dysport, Xeomin, Daxxify, or Jeuveau) seems to “stop working” over time.
“Neurotoxins refer to substances produced by clostridium botulinum,” says New York dermatologist Marisa Garshick, MD. “They work by blocking the release of acetylcholine at the neuromuscular junction, which prevents muscle movement. As a result, it reduces the appearance of expression lines.” However, neurotoxin injections are not a silver bullet for everyone. These are the reasons why they may seem to stop working or not work at all, according to experts.
Featured experts
- Doris Day, MD, a board-certified dermatologist based in New York
- Julie Russak, MD, a board-certified dermatologist based in New York
- Kimberly J. Lee, MD, a board-certified facial plastic surgeon based in Los Angeles
- Marisa Garshick, MD, a board-certified dermatologist based in New York
- Michael Suzman, MD, a board-certified plastic surgeon based in Purchase, NY
Reason #1 Why Your Neurotoxin Is “Not Working”: You get the injection too often
According to New York dermatologist Doris Day, MD, the longer you’re exposed to a neurotoxin, the more likely you are to develop a resistance to it. “This is because of the way neurotoxins are processed,” he explains. “If you’re injected and then you wait three months, the drug is completely out of your system and completely worn off. So the next time you get it, it’s like getting it for the first time.”
On the other hand, some people do “Baby Botox” more often. “This means you get fewer units every four to six weeks,” says Dr. Day. “These patients are at increased risk of developing immunity to the neurotoxin. It’s not that they want to look frozen, but some people may benefit from treatments more often to get the look they want. However, if you continue to inject again and again at intervals of less than two months, you are more likely to develop resistance. The way to minimize the problem is to make sure you stop your treatments every three to four months.”
New York dermatologist Julie Russak, MD, agrees, saying that the body can develop antibodies to a particular product and your immune system will fight back. “In most cases, people make antibodies to the helper protein Botox Cosmetic and Dysportinstead of the active molecule’.
The only product on the market with which the resistance would not occur is Xeomin, says Dr. Day. “All other neurotoxins available in the US are formulated with binding proteins. Xeomin is the only pure form of the drug without other elements that could create an antibody response. I use it very precisely and have fantastic results. I can also modify the treatment based on the patient’s goals.”
Reason #2: You are part of the 4 percent
Los Angeles facial plastic surgeon Kimberly J. Lee, MD says patients can be completely resistant to neurotoxins. “About 4 percent of the population is resistant to neurotoxins, meaning they have no effect from the injection.”
Reason #3: It may be the result of natural aging
According to Purchase, New York plastic surgeon Michael Suzman, MD, there’s a chance the neurotoxin is still working, but you perceive it differently many years after the injection. “If a patient sees a diminished effect after receiving regular injections, it may be because they are so used to the smooth appearance they have achieved. But because they still age normally over time, they see less of a ‘youthful’ effect,” he explains.
Reason #4: You didn’t go to a special injector
Neurotoxins have been around for decades and are extremely quick to administer—my forehead and glabella took less than five minutes total—but that doesn’t mean they shouldn’t be considered serious surgery. Injecting anything into the face should be left to a board certified dermatologist or plastic surgeon or Expert Injector. “Another reason someone might think their neurotoxins aren’t working is if the injection missed the strongest part of the muscle. It may have accumulated between areas of the muscle where it is less effective,” says Dr. Suzman. “A touch of the product from a fresh vial should correct the problem. Always make sure you get treatment from someone who is properly qualified and trained.”
Can You Reverse Botox Resistance?
While Dr. Garshick says you can’t necessarily reverse Botox resistance, there are some strategies to overcome it. “The solution may be to use a different type of botulinum toxin,” he explains. “For example, if someone finds that they develop a resistance to Botox, they may prefer to switch to Xeomin, Dysport or Jeuveau. Or, they can switch to another strain of neurotoxin, such as botulinum toxin type B. [Neurotoxins use botulinum toxin type A.] However, this is not as easy to find among cosmetic injectors and does not last as long. Another option might be to look at the neurotoxin Daxxify, which is thought to last longer.’
“You might also consider taking a zinc supplement, which can help the neurotoxins last longer,” says Dr. Garshick. “More data are needed, but one small study showed that zinc should be taken four to five days before neurotoxin injections and on the day of the injection to help the toxin bind to its target. Another option is to take a break from neurotoxin injections for six to 18 months to see if that gives your body time to clear any circulating antibodies.”
However, with all that being said, Dr. Day says she doesn’t see this “immunity” happening very often. “In my 20 years of using Botox and other neurotoxins, it’s not often that I see this problem. But now we’re starting to use these products a lot more often in the form of ‘Baby Botox,’ so I think we’re going to start seeing more of that.”
