by Kate Dee, MD
Most everyone has heard of Botox by now. In fact, Botox has become a lot like Kleenex-- no matter what treatment people are getting for facial wrinkles, we tend to call it all Botox. But there are currently 4 neurotoxins that are FDA approved in the US and one more expected later this year (2020). Botox is the number one toxin in the US and Dysport is the number one in Europe. These 4 versions of botulinum toxin are very similar. How do they all differ? Does it matter which one you use? Do I have a preference?
All 4 are made from the toxin produced by the bacterium clostridium botulinum. Yes-- that’s the one that causes Botulism! The companies (Allergan makes Botox, Galderma makes Dysport, Merz makes Xeomin and Evolus makes Juveau) then make proprietary changes to produce their own product. The active part of the toxin consists of 2 protein subunits that are at the center of each of these. This is the exact same for all 4 of these products. The way they differ is in the additional proteins attached to that active part. Botox has a large protein coat that gives it some of its chemical properties. Dysport also has a protein coat, but it is smaller than that of Botox. Xeomin has no protein coat. Lastly, Juveau has a large one, similar in size to Botox.
Because the toxins have different proteins attached, they have slightly different properties in the body. Botox takes 1-2 weeks for its full effect and lasts about 3-4 months in most people. Many people like Dysport because it acts faster (3-5 days) and lasts a little longer (4+ months) than Botox. Xeomin takes just as long as Botox to set in (1-2 weeks) and does not last as long as Botox. (For this reason, many doctors, including myself, have stopped using it.) The new one on the block, Juveau, is very similar to Botox-- most people think it lasts as long or almost as long as Botox. What’s the advantage of Juveau over Botox? The price-- Juveau is usually less expensive.
Because of the protein coat, Botox, Dysport and Juveau are prone to breaking down at room temperature so they must be shipped and stored cold. Xeomin is stable as a powder and does not need to be kept cold. Xeomin is popular for injectors who travel around with the toxin, since they can drive or fly with it without its losing efficacy.
Allergies to these toxins are very rare. But any protein can be targeted by our immune system. Because Botox has the most protein, in theory, there is the highest chance of an allergy with it; however, because allergies are so rare, this has never been demonstrated in any study.
People can also develop antibodies to the toxins, which results in their bodies clearing the toxin so it has no effect. In theory, if you have an allergy or antibodies to Botox, then there is a chance you won’t be allergic to one or more of the others. In fact Merz touts how they have “minimized the foreign material (xeo)” and hence the name “Xeo-min” rests on the idea that there is the least chance of an allergic reaction. Because allergies are rare this is hard to prove.
This part is sometimes confusing for people. The units of Dysport are different from the others as there is no standardized way of measuring this. Dysport units are about 3:1 equivalent to Botox. So one vial of Botox is 100U while one vial of Dysport is 300U. These products are all diluted exactly the same way, and the volume of fluid used is exactly the same. The number of units is different. Some Botox advocates post ideas out there that “Botox is 3x as strong as Dysport.” This is a very misleading idea. The Units are different. If you normally get 20U of Botox, you will get 60U of Dysport for the same treatment. The cost is comparable or slightly less for Dysport in most offices.
As I already mentioned, I no longer use Xeomin because it just doesn’t last long enough. I like both Botox and Dysport, and use them both daily. I do like Dysport because it acts faster and lasts longer in most people (including in me-- so that’s what I’ve got in my corrugators right now!). For those who see no difference, they are both fantastic options. Juveau has not been around very long, and because it is so similar to Botox, I would say go for it if you like it and can save money!
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