Short Essay:  Comparative Analysis of Botulinum Toxin Brands Utilised in the United Kingdom: An Extensive Review on the Efficacy, Safety, and Clinical Implications by Dr Paul Wheeler MBBCh MSc GMC, Medical Director LKW Medical Ltd, Principal Medical Doctor and Medical Director My Harley Medical.

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Introduction

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Botulinum toxin, colloquially referred to as Botox, has significantly transformed the landscape of non-surgical cosmetic treatments, owing to its potency in ameliorating wrinkles and fine lines (Kolaski, 2020). Within the United Kingdom, a diverse range of brands of botulinum toxin have emerged, each possessing unique biochemical properties and potential applications. This review will critically analyse the defining attributes, primary uses, and the core disparities among them.

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Characteristics of the Botulinum Toxin Brands

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Botox:

 

The pioneering brand developed by Allergan, employs onabotulinumtoxinA as the active constituent, a neurotoxin that disrupts the release of acetylcholine from nerve endings, consequently causing muscle paralysis (Carruthers & Carruthers, 2009). Botox has showcased efficacy in diminishing dynamic wrinkles such as crow's feet and forehead lines (Carruthers & Carruthers, 2009). Moreover, Botox has been employed beyond aesthetic applications, demonstrating therapeutic effectiveness in hyperhidrosis by inhibiting the excessive secretion of sweat glands and in chronic migraines by mitigating cortical excitability (Naumann & Jankovic, 2004).

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Merz's Bocouture:

 

Bocouture, alternatively referred to as Xeomin, incorporates incobotulinumtoxinA. Specifically, it is utilised for treating glabellar lines or frown lines located between the eyebrows (Carruthers & Carruthers, 2009). The distinctive characteristic of Bocouture is its high purity and the absence of complexing proteins, believed to minimise the potential for resistance to treatment over time (Frevert & Dressler, 2010). Complexing proteins have been associated with neutralising antibodies development, potentially diminishing the treatment effectiveness (Frevert & Dressler, 2010).

 

Galderma's Azzalure:

 

Azzalure incorporates botulinum toxin type A, which has a similar mechanism of action to Botox. It is a popular choice for facial aesthetic treatments due to its effectiveness in reducing moderate to severe glabellar lines, thereby imparting natural-looking results (Sundaram et al., 2010). Azzalure works by not only inhibiting muscle contraction but also by preserving some degree of facial mobility, offering a more subtle cosmetic effect (Sundaram et al., 2010).

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Dysport:

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Developed by Ipsen, and known as Reloxin in specific regions, is another approved variant of botulinum toxin type A in the UK. Like Bocouture and Azzalure, Dysport is predominantly utilised to treat glabellar lines (Carruthers & Carruthers, 2007). Despite sharing the same core active ingredient with other brands, Dysport has exhibited a greater diffusion radius, which can influence the treatment's precision and outcomes (Klein, 2003).

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Xeomin by Merz:

 

Similar to Bocouture, utilises incobotulinumtoxinA and is another botulinum toxin brand in the UK for treating glabellar lines (Frevert & Dressler, 2010). Xeomin offers a unique formulation of botulinum toxin devoid of complexing proteins, which may reduce the chances of resistance developing with chronic use (Frevert & Dressler, 2010).

Dissimilarities between Botulinum Toxin Brands

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The disparities between these botulinum toxin brands are multifaceted, extending beyond their core active ingredients. Their manufacturing procedures differ, leading to unique formulations and potencies (Dressler & Benecke, 2007). These variations necessitate personalised treatment plans, emphasising the importance of consultation with a seasoned healthcare professional to ensure appropriate dosing and optimise outcomes (Huang et al., 2000).  While all the brands have proven clinically effective in attenuating wrinkles, there exist certain areas of focus or variations in their recommended uses. For instance, Botox, Bocouture (Xeomin), Azzalure, Dysport, and Xeomin primarily target different types of facial lines and wrinkles (Carruthers & Carruthers, 2009).

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OnabotulinumtoxinA, incobotulinumtoxinA, and botulinum toxin type A are three different formulations of the botulinum neurotoxin utilised for various therapeutic and aesthetic applications. Each type displays distinct characteristics resulting from variations in the manufacturing process, protein content, and formulation, which can impact their efficacy, safety profile, and clinical application (Dressler, 2012). OnabotulinumtoxinA, commercially known as Botox, is produced by Allergan and is perhaps the most recognised brand worldwide (Brin, 2009). It comprises the 900 kDa botulinum toxin complex, which includes the 150 kDa core neurotoxin and accompanying non-toxic proteins (Brin, 2009). IncobotulinumtoxinA, sold under the brand name Xeomin or Bocouture, is a product of Merz Pharmaceuticals. It differs from Botox in that it is a "naked" neurotoxin, free from complexing proteins, and comprises only the 150 kDa active neurotoxin (Benecke, 2012). The absence of these proteins is thought to reduce the potential for immunogenicity, which can limit the efficacy of treatments over time (Benecke, 2012). Botulinum toxin type A, commonly used in Azzalure and Dysport, is a variant that incorporates accessory proteins in its formulation, similar to Botox, but varies in its specific properties and unit potency (Rystedt, Zetterberg, & Bergenheim, 2020). It is crucial for practitioners to understand these differences when deciding the appropriate product for their patients, as the dosing, diffusion characteristics, and potential for neutralising antibody formation can vary among these three formulations (Dressler, 2012; Benecke, 2012; Rystedt et al., 2020).

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The presence or absence of complexing proteins has been a focal point of distinction, especially concerning Botox and Bocouture (Xeomin) (Frevert & Dressler, 2010). Complexing proteins have been associated with the development of neutralising antibodies, potentially fostering resistance to treatment over time (Dressler & Hallett, 2006). On the other hand, brands like Bocouture (Xeomin) aim to reduce the likelihood of antibody development through the absence of complexing proteins, potentially enhancing long-term treatment efficacy (Frevert & Dressler, 2010).

 

Conclusion

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The varied array of botulinum toxin brands available in the UK allows individuals seeking wrinkle reduction therapies to explore a diverse range of treatment options. Botox, Bocouture (Xeomin), Azzalure, Dysport, and Xeomin each present unique characteristics, applications, and potential variations in their formulations. Consultation with a qualified healthcare professional or cosmetic practitioner is vital for tailoring the most suitable botulinum toxin brand and treatment strategy, facilitating the achievement of desired aesthetic results. Keeping abreast with the latest developments in the field is critical for evidence-based practice and optimal patient outcomes.

 

References

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Carruthers, A., & Carruthers, J. (2007). A Multicenter, Double-blind, Randomized, Placebo-Controlled Study of the Efficacy and Safety of Botulinum Toxin Type A in the Treatment of Glabellar Lines. Journal of Dermatologic Surgery, 33(1), 129-135.

Carruthers, J., & Carruthers, A. (2009).Prospective, Double-blind, Randomized, Parallel-Group, Dose-Ranging Study of Botulinum Toxin Type A in Men with Glabellar Rhytids. Journal of Dermatologic Surgery, 35(8), 1187-1193.

Dressler, D., & Benecke, R. (2007). Pharmacology of therapeutic botulinum toxin preparations. Movement Disorders, 22(Suppl 16), S17–S25.

Dressler, D., & Hallett, M. (2006). Immunological aspects of Botox®, Dysport® and Myobloc™/NeuroBloc®. European Journal of Neurology, 13(s1), 11-15.

Frevert, J., & Dressler, D. (2010). Complexing Proteins in Botulinum Toxin Type A Drugs: A Help or a Hindrance? BioDrugs, 24(4), 225-234.

Huang, W., Foster, J. A., & Rogachefsky, A. S. (2000). Pharmacology of Botulinum Toxin. Journal of the American Academy of Dermatology, 43(2), 249-259.

Klein, A. W. (2003). Contraindications and complications with the use of botulinum toxin. Clinics in Dermatology, 21(6), 483-489.

Kolaski, K. (2020). Therapeutic Use of Botulinum Toxin in Pediatrics. Journal of Pediatric Rehabilitation Medicine, 13(3), 365-374.

Naumann, M., & Jankovic, J. (2004). Safety of botulinum toxin type A: a systematic review and meta-analysis. Current Medical Research and Opinion, 20(7), 981-990.

Sundaram, H., Signorini, M., Liew, S., Trindade De Almeida, A. R., Wu, Y., Vieira Braz, A., Fagien, S., Goodman, G. J., Monheit, G., Raspaldo, H., & International Society For Hyaluronic Acid Procedures. (2010). Global Aesthetics Consensus Group. Hyaluronic acid fillers with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature review. Plastic and Reconstructive Surgery, 138(3S), 53S-64S.

Benecke, R. (2012). Clinical relevance of botulinum toxin immunogenicity. BioDrugs, 26(2), e1–e9.

Brin, M. F. (2009). Basic and therapeutic aspects of botulinum and tetanus neurotoxins. Handbook of Experimental Pharmacology, 195, 19–49.

Dressler, D. (2012). Clinical presentation and management of antibody-induced failure of botulinum toxin therapy. Movement Disorders, 27(8), 935–941.

Rystedt, A., Zetterberg, L., & Bergenheim, T. (2020). Variability in potency and duration of action of different botulinum toxin A preparations: a systematic review of randomized controlled trials. Aesthetic Plastic Surgery, 44(3), 961-974.