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The use of botulinum toxin treatments have certainly changed what’s possible for our appearance, particularly as we age.
The injectable treatments are used to reduce the appearance of facial wrinkles and fine lines by temporarily relaxing movement in the muscles that cause them, and have become widely available in recent years.
So effective is botulinum neurotoxin-A (BoNT-A) to help smooth a strong frown line, creased forehead or crinkly crow’s-feet, many of us have been committed to keeping up with regular appointments.
What is botulinum toxin resistance?
What some people may not know, however, is that research has shown it’s possible to develop resistance to botulinum toxin, the active ingredient in anti-wrinkle injections.¹
Two new surveys commissioned by Merz Aesthetics, the world’s largest dedicated medical aesthetics business, show the number of people experiencing declining efficacy in their anti-wrinkle injections, is increasing. Importantly, it also reveals consumer habits may be exacerbating the issue.
Not only can this be an issue in terms of achieving less than ideal anti-wrinkle results, but also because it may impact the effectiveness if botulinum neurotoxin-A (BoNT-A) is needed for therapeutic reasons. It can be used to treat a number of medical conditions, including those associated with overactive muscles.
Resistance can happen when your body has developed antibodies which attach to, and deactivate botulinum toxin, preventing it from working as intended.
The risk of developing resistance is thought to be lower while using the lowest possible dose and avoiding frequent ‘top-ups’. Another recommendation to reduce the risk includes using a botulinum toxin which is highly purified to remove non-essential components*, such as Xeomin.
Surveys show lack of understanding
The two surveys, carried out across Asia-Pacific between June and September 2024, reveal understanding of the issue is varied. One survey focused on consumers, while the other targeted health care professionals. 81%² of surveyed consumers reported declining efficacy in botulinum toxin treatments, up from 79%³ in 2021 and 69% in 2018.⁴
While some of these consumers were aware of the potential contributing factors, 50% of them still took actions that may have worsened the problem, including increasing treatment dosages or reducing the time between treatments.²
The results of the survey were presented at the 12th Dermatology, Aesthetics, and Surgery International League (DASIL) World Congress in Hanoi, Vietnam, by an international multidisciplinary panel, the Aesthetic Council for Ethical use of Neurotoxin Delivery (ASCEND).
A case of complete botulinum toxin A resistance with aesthetic treatment was shared by Dr. Siew Tuck Wah, Aesthetic Physician and Medical Director of Radium Aesthetics at the Congress, where the patient took three years to start responding to treatment again. “As it’s not possible to predict how long it takes for neutralising antibodies to resolve, it can take several years and, in some cases, it may be irreversible, prevention is always better than cure,” he said. “The most prudent option is to start treatment with a pure⁺ formulation from the beginning, or switch to it as early as
possible before a patient starts to develop signs of botulinum toxin immunoresistance.”
The study confirms patients are not fully aware that they can develop immunity to BoNT-A treatments, according to Dr. Niamh Corduff, FRACS, Plastic Surgeon and Clinical Director of RiverEnd Aesthetics in Australia.
“One of the strategies to prevent this is to ensure that a pure BoNT-A formulation is used,” Dr. Corduff said. “With the wide range of BoNT-A options available, it’s crucial for the industry to clearly define what constitutes a truly pure formulation, and to highlight the important role of toxin purity in minimising the risk of immunogenicity. This enables patients and HCPs to together make an informed decision that ensures safety and efficacy of botulinum toxin treatments for both aesthetic and medical purposes in the long run.”
Education is key agrees the experts, and health care providers should mention BoNT-A immunoresistance could be a potential side-effect when taking informed consent for treatment.
About the Consumer and HCP Surveys
The surveys were commissioned by Merz Aesthetics and undertaken by Frost & Sullivan. The consumer fieldwork took place from June to August 2024, and the HCP fieldwork from August to September 2024.
The consumer survey collected data from 2,588 botulinum toxin users across 9 APAC territories including Australia, Hong Kong SAR, Indonesia, Malaysia, Philippines, Singapore, South Korea, Taiwan, and Thailand, who have had at least three treatments with botulinum products containing additional non-essential components *.
The HCP survey collected data from 242 medical aesthetics clinicians across 8 APAC territories including Australia, Hong Kong SAR, Indonesia, Philippines, Singapore, South Korea, Taiwan, and Thailand.
+ Pure refers to the absence of complexing proteins, inactive neurotoxin, flagellin and bacterial DNA contaminants [1]
* Additional non-essential components refer to the presence of complexing proteins, inactive neurotoxin, flagellin and bacterial DNA contaminants [1]
References:
1. Park JY, Sunga O, Wanitphakdeedecha R, Frevert J. Neurotoxin Impurities: A Review of Threats to Efficacy. Plast Reconstr Surg Glob Open. 2020;8(1): e2627.
2. Based on a consumer market study conducted in 2024 on “Consumer Experience with Declining Treatment Effects”; by Merz Aesthetics in partnership with Frost & Sullivan across 9 Asia Pacific territories (Australia, Hong Kong, Indonesia, Malaysia, Philippines, Singapore, South Korea, Taiwan and Thailand) and included 2,588 Botulinum toxin users from the ages of 21 to 55 years old.
3. Based on a consumer market study conducted in 2021 on “Consumer Experience with Declining Treatment Effects” by Merz Aesthetics in partnership with Frost & Sullivan across 8 Asia Pacific territories (Australia, Hong Kong, Indonesia, Singapore, South Korea, Philippines, Taiwan and Thailand) and included 2,441 Botulinum toxin users from the ages of 21 to 55 years old.
4. Based on a consumer market study conducted in 2018 on “Consumer Experience with Declining Treatment Effects” by Merz Aesthetics in partnership with Frost & Sullivan across 8 Asia Pacific territories (Australia, Hong Kong, Indonesia, Singapore, South Korea, Philippines, Taiwan and Thailand) and included 2,441 Botulinum toxin users from the ages of 21 to 55 years old.
5. Corduff N, Park JY, Calderon PE, Choi H, Dingley M, Ho WWS, Martin MU, Suseno LS, Tseng FW, Vachiramon V, Wanitphakdeedecha R, Yu JNT. Real-world Implications of Botulinum Neurotoxin A Immunoresistance for Consumers and Aesthetic Practitioners: Insights from ASCEND Multidisciplinary Panel. Plast Reconstr Surg Glob Open. 2024;12(6):e5892.
6. Based on an aesthetics healthcare professionals market study conducted in 2024 on “HCPs Experience with Declining Treatment Effects Among Botulinum Toxin Users”; by Merz Aesthetics in
partnership with Frost & Sullivan across 8 Asia Pacific territories (Australia, Hong Kong, Indonesia, Philippines, Singapore, South Korea, Taiwan and Thailand) and included 242 aesthetic healthcare practitioners.
Xeomin ® (Incobotulinumtoxin A) 50, 100 Units is a Prescription Medicine. Indications: In adults, for the treatment of cervical dystonia; blepharospasm; spasticity of the upper limb; upper facial lines: glabellar frown lines, lateral periorbital lines (crow’s feet), horizontal forehead lines. Xeomin has both risks and benefits, consult your doctor to see if Xeomin is right for you. Further information on the risks and benefits of Xeomin can be found in the Consumer Medicine Information (CMI) available from www.medsafe.govt.nz or by calling 0800 822 310. Use strictly as directed. If symptoms continue or you have side effects, see your doctor, pharmacist or health care professional. Common side effects include: Headaches; nausea; tenderness, swelling, redness, numbness or bruising of the skin; dry eye; heavy feeling of eyelid/eyebrow/forehead; face/brow not symmetrical, dropping eyelids/eyebrows. Serious side effects are rare and include allergic reactions. Xeomin is an unfunded medicine, prescription charge will apply. Normal doctor charges will still apply.
Copyright © 2025. Pharmacy Retailing NZ Limited t/a Health Care Logistics (HCL) 58 Richard Pearse Drive, Mangere, Auckland 2022. All rights reserved. Xeomin ® and Merz Aesthetics are registered trademarks of Merz Pharma GMbH & Co. KGaA. Date of preparation: January 2025. For information about how Merz handles personal data, please see Merz General Data Protection Information Notice at www.merz.com/fin. TAPS MR12038.
