-“Doctor, don’t throw it…Put it in my forehead to get rid of these awful wrinkles.”

The request to inject any residual Botulinum Toxin for cosmetic remedy is a common occurrence in the offices that use it for FDA-approved indications. Initially developed by Dr. Alan Scot to treat strabismus in children, the drug has been proved to be safe and effective to treat a big number of conditions, many of them already FDA-approved.

Botulinum toxin binds to specific receptors in the presynaptic membrane and prevents the formation of the SNARE complex and the fusion of the vesicle with the cellular membrane. As a result acetylcholine, a critical substance for neuromuscular transmission, is not released into the muscle-nerve cleft. The muscle fibers are thus paralyzed and the contraction/spasticity eases down.

In the US there are two serotypes of botulinum toxin that are used for human therapeutics: type A and type B. Three forms of Type A and one of Type B are commercially available at the present time. Each of these toxins has different manufacturing, potencies and dilution requirements; the scientific data concerning their safety and efficacy differs widely amongst studies.

Updating its 2008 guidelines on Botulinum toxin, the American Academy of Neurology has released new clinical practice guidelines for its use for the treatment of blepharospasm, cervical dsytonia, adult spasticity and headache. In 2008 there was not enough data to recommend it for chronic migraine but randomized, double-blind, placebo-controlled studies of the Onabotulinum toxin A (popularly known as Botox) showed reduction of headache days.

The magnitude of the change in headache days is small but statistically significant; in the four weeks after the first treatment, the patients that took onabotulinum toxin A had 15% fewer headache days compared with those receiving the placebo. The Food and Drug Administration has approved its clinical use for the treatment of chronic migraine.

Botulinum treatment is based in solid science but it is also an art. Technical issues include what muscles to inject, dosage per muscle and dilution details. The final outcome also depends on the patients’ previous expectations and their physiological responses to it.

What do you think? Please tell us.

Don’t leave me alone.

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