Continuing medical education
Injectable and topical neurotoxins in dermatology: Indications, adverse events, and controversies

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The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.

Section snippets

Therapeutic indications

Key points

  1. The therapeutic use of botulinum toxin has spanned across multiple specialties

  2. Disorders of sweating, flushing, and scar prevention are some of the dermatologic therapeutic usages of neuromodulators

  3. Other specialties highlighting the use of neuromodulators for therapeutic purposes include psychiatry, neurology, ophthalmology, gastroenterology, and urology/gynecology

  4. Off-label usages are common, and new usages are continuously under investigation

  5. Hypersensitivity reactions to the product and

Combination cosmetic therapy: Dermal fillers, lasers, and light sources

Key points

  1. Combination treatment of neurotoxins and soft tissue augmentation provides greater improvement and longer-lasting results with static facial rhytids

  2. Ideally, injecting toxin and waiting a short period of time before performing filler can reduce the total amount of filler required; however, many patients prefer treatment in the same session for convenience

  3. Neurotoxin combined with energy based devices is superior to either modality alone

  4. Caution is advised injecting toxins concurrently with

Adverse events and complications: Prevention, recognition, and treatment

Key points

  1. Injection site discomfort, erythema, bruising, and temporary headaches are the most common side effects

  2. Injection into a pilosebaceous unit can reduce pain

  3. Many of the functional/cosmetically displeasing adverse events may be prevented with very superficial, low volume injections

  4. Dysphagia, hoarseness, and neck flexor weakness are rare risks when injecting the platysma

Neurotoxins have consistently proven to be remarkably safe. Most reactions are a result of injection technique, dosage, or volume,

Controversies

Key points

  1. The development of neutralizing antibodies is more complex than previously speculated

  2. Antibodies to toxin type A may not always confer resistance to the other serotypes (ie, type B)

  3. Proper training requirements should be established and enforced for all physician and nonphysician injectors

  4. Muscle atrophy remains a topic of debate with regard to the cosmetic use of botulinum toxin

Summary

The use of neuromodulators continues to revolutionize medicine. The attractive quality of these agents is partly derived from their remarkable safety profile, minimally invasive approach, and overall ease of use for the physician. New indications are continuously emerging in the dermatologic and nondermatologic literature, expanding the utility and popularity of these products across multiple specialties. As the demand for a more youthful appearance continues to rise, neuromodulators will play

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    Funding sources: None.

    Conflicts of interest: None declared.

    Reprints not available from the authors.

    Date of release: June 2017

    Expiration date: June 2020

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