Clinical indications and use

Abstract

Botulinum toxin is used for cosmetic (45%) and noncosmetic (55%) indications. It is effective as a skeletal muscle relaxant, an antispasticity agent, for essential tremor and for trigeminal neuralgia. Botulinum toxin acts at the autonomic junctions to treat hyperhidrosis and reduce sialorrhoea. It works on involuntary muscle contraction and is effective for internal organ spasticity. It modifies the effect of pain mediators and is effective in chronic migraine.

Cosmetic indications include elimination of wrinkles around the eyes (crow’s feet), forehead lines, vertical glabellar (frown) wrinkles, perioral lines, neck rhytids and lip lines. The concentration of the preparation of botulinum toxin is directly related to the desired degree of diffusion of effect and the desired duration of effect. The different serotypes are assessed with different unit assays, and 100 BOTOX units are equivalent to 400 AZZALURE/Dysport units. Various concentrations may be used to reduce or extend the duration of effect. The author recommends using a constant concentration of botulinum toxin whilst varying the volume injected to develop the intuitive art of choosing the correct degree of diffusion over underlying muscles and glands.

Keywords

Botox, Dysport, Azzalure, Xeomin, diffusion, dose, concentration

The cosmetic indications for botulinum toxin have not changed since the first edition of this book and are listed in Box 3.1 , but the noncosmetic indications now represent 55% of all botulinum toxin use. In the author’s oculofacial practice, botulinum toxin is an essential first-line treatment for hemifacial and blepharospasm, post–facial nerve palsy synkinesis, chronic migraine, frontal ‘trigeminal’ headaches and hyperhidrosis. Table 3.1 provides a list of other uses at the time of press.

Much has been published on the differences between the different products, and the reader is referred to an excellent 2018 review on the same by Dr. Richard Glogau.