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Botox: What to know before you ask

May 6, 2019 / Håvard Liltved Dalen

‘Botox’ is all over the place

It’s the brand name of one commercial preparation (there are others) of Clostridium botulinum toxin, a bacterium-derived poison – the one that used to kill people in the days when we canned our own fruit. Botulism was the ensuing disease, and it was pretty deadly.

Injections with little amounts of this toxin are routine these days in treatment of certain kinds of muscle contractures, bladder dysfunction, chronic migraine, and excess sweating.

It’s also popular for treating cosmetic conditions, like crow's feet, frown lines, wrinkles on the nose, upper lip rhytids, and neck bands.

People like to say it ‘smooths’ wrinkles, and ‘relaxes’ local muscles. They like to think that it ‘wears off’, and then you simply get more treatment. Language like this makes the whole process sound natural, gentle, soothing, and healing.

It´s not a cure for anything – it works by damaging

But actually, Botulinum is a neurotoxin. It blocks the release of an activating chemical, called acetylcholine, between the neurons where it’s injected. It effectively destroys the little synaptic junctions there. And the associated muscles are paralysed. After that, the muscles atrophy. It stiffens tissue, and that, if it's done gently, does sort of make you look a little younger.

This synaptic damage is permanent. You think the effect wears off, but that’s only because your neurons sprout new axons and make new connections with other neurons. Then muscles can move again. And sag. And then you're tempted to go back for more injections.

But to say it again, you’re dealing with a neurotoxin.

That’s why there are contraindications to this treatment …

… that center on neuromuscular junction disorders, like myasthenia gravis, and amyotrophic lateralizing sclerosis, and myopathies in general. Pregnancy and breastfeeding, for other reasons, are also times when you shouldn’t get these shots.

And that’s why there are side effects …

… like inflammation at the injection site (another reason wrinkles sometimes seem to disappear), or headaches, or droopy eyelids, or crooked, drooling smiles, or the feeling that you’ve got the flu.

You’ve poisoned yourself, basically.

And there may be systemic toxic effects

We don’t know for sure yet, but it’s looking like botulinum toxin in ‘safe’ amounts may be able to spread through your system. That’s why the manufacturers caution doctors who administer it to watch for possible muscle weakness, breathing problems, trouble seeing, and other pretty scary side effects. It’s for this reason that some dermatologists no longer do botulinum injections for cosmetic reasons at all.

So know before you go

If you do want Botulinum toxin injections, have it managed by a dermatologist at least. Cosmeticians sometimes offer ‘treatment’, but this is for doctors to do, not amateurs.

One more word, about creams

The Botulinum molecule is huge. Actually, it’s a molecule within another molecule, a whole complex that measures a good 500 kilodaltons. That’s way too big to go through your skin. Furthermore, that molecule appears to carry an electrical charge that makes it naturally repel from your skin, which carries its own charge. It has to be forced through, which is why there are injections. This was confirmed in the course of some breakthrough research in ‘transdermal’ delivery of the toxin for control of excess sweating in the hands. The injections hurt. So the research team tried it by 'iontophoresis', a way of driving the molecule through the skin painlessly (probably down the sweat pores), by using a mild electrical field in diluted salt water. It worked. Without the iontophoresis machine, though, the team just couldn’t make the toxin go in. The point is, on the evidence of that research, and on the basis of what we know about the molecule itself, there's no reason to think you can simply rub Botulinum toxin into your skin. It doesn't appear to go. So if you see a topical Botulinum cream preparation for sale, and there are some on the market, be sure you can find documented evidence that it works before you buy it.

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