It’s a recurring question in aesthetic medicine practices, and a visit to Internet message boards shows it’s one that doctors and patients have been asking for years: Is it true that the effects of Botox, the brand that two decades ago became the popular generic name for botulinum toxin, is it increasingly short-lived?
The implications of this question go far beyond private doubts in front of one’s bathroom mirror. First, because of its economic impact. Botulinum toxin is the most widely used treatment in cosmetic medicine. Last year, 332,000 vials of the drug were sold in Spain for cosmetic purposes at a cost of $85 million, according to figures provided by specialist consultancy Iqvia. And secondly, because the discussion is highly scientific in subject matter dozens of articles published in medical journals and untold hours of speaking time on industry forums.
“It is true that the effects of the toxin sometimes last less than expected. But its causes, in general, are not so much in the substance itself, but in the characteristics of the patient or in insufficient administration”, says Fernando García Monforte, a doctor specializing in the field and co-author of a recently published study in a scientific journal. Medicina Esthetica with Title Botulinum toxin. ¿Por qué dura menos? A review from our experience (in English, Botulinum toxin: Why does it less? A review based on our experience).
The substance comes from a protein produced in nature by bacteria of the species Clostridium botulinum. Due to its strong neurotoxic action, it poses a risk in the food sector, where it can cause severe poisoning in the form of botulism when these microorganisms contaminate edible products such as canned food. “It causes muscle paralysis by inhibiting the release of acetylcholine, which is the transmitter used by neurons to communicate with each other. In practice, this causes the nerve endings to stop sending commands to the muscles,” explains Francisco Zaragoza, professor of pharmacology at the University of Alcalá de Henares in Madrid.
The same effect that makes it dangerous—a person intoxicated by the bacteria will suffocate to death when their respiratory muscles stop working—gives the toxin enormous potential in the medical field if applied topically in small doses. In aesthetic medicine, botox is commonly used to “eliminate or soften facial wrinkles, such as those on the forehead, between the eyebrows and around the eyes,” says Juan Antonio López Pitalúa, president of the Spanish Society of Aesthetic Medicine (SEME). In other areas of medicine, the toxin is used in various muscle conditions—particularly dystonia—and for certain types of migraines, among other conditions.
García Monforte’s article presents the problem in its first paragraph: “Complaints about the shorter duration of the toxin’s effect on patients cause concern among physicians,” as “it is common to hear that, when a new treatment is performed with the same brand toxin as a previous treatment, that the duration of the effect is shorter.”
Answering questions from EL PAÍS, the author details several factors that shed light on this apparent mystery. “Some of it has to do with how the toxin is delivered. It is a protein that can degrade if not treated properly, which can reduce its effectiveness and therefore the duration of its effects. I like to say that the toxin lasts less when administered by certain people,” he says. Shaking the product, for example, should be avoided at all costs. The manufacturer’s instructions should also be followed in detail when reconstituting the toxin, which is sold in vials containing a powder that must be diluted in saline and then kept at a low temperature.
“If used too often, the body will develop antibodies that can also shorten the effects,” says García Monforte. To avoid this, injections should be spaced out for cosmetic reasons, but it’s important to also keep in mind that the toxin is used in the health care system for various neurological, muscle, or pain-related conditions. “People often don’t make the connection that the drug they’ve been injected with in the hospital is the same or very similar to what we use. That’s why you should always ask for all the information, including the brand. Not all toxins are the same and we can achieve better results if we consider all these factors,” says the doctor.
Finally, experienced doctors know that other factors can play a role. “The effects of the toxin last less in the summer, for example. This is due to the heat and sun, which warm the skin and help degrade the toxin. People who go through stressful times also tend to have less long-lasting effects. In general, anything that involves more activity, intensity or movement can shorten the results,” says García Monforte.
With so many issues at play, it is “normal that there is some difference in the results obtained,” says García Monforte, who says that “although it is said that the toxin lasts up to six months, we actually have to think about it as it lasts three months, and from then on, consider it a gift, attainable by accurate use.”
López Pitalúa explains it in other words. “The use of this drug should be evaluated over a period of six months. During the first two months, the paralysis is complete. Over the next two months, the muscle gradually regains mobility. And in the last two months, although he has almost fully recovered, the wrinkles will tend to be less pronounced because of the time the muscle has relaxed,” says López Pitalúa.
Also, patient preferences are not always the same. “There are some people who like the results of the first few weeks better. Others, on the contrary, look better a month and a half or two months after the injection. It depends on one’s taste, there is a lot of variety,” he adds.
According to García Monforte’s article, “those responsible for the production and distribution of the toxin deny that there is a manufacturer-dependent cause of the toxin’s reduced effectiveness.” EL PAÍS asked two of the major manufacturers of the versions of the drug used in aesthetic medicine, Merz and Allergan, but both declined to comment.
Experts polled admit that it would be very difficult to end this debate, in part because of the large number of factors that can affect results and in part because of the significant subjective component that makes “each person and each unique treatment .”
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