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New developments in Botox

Popular neurotoxin continues to receive praise as new options are being prepared for market


Kohala Coast, HI When giving botulinum toxin type A (Botox, Allergan) to patients, dermatologists should tell them that it "relaxes the muscles temporarily. Let’s not say paralyze," said Susan Weinkle, M.D., at the Winter Clinical Dermatology Conference.

After offering that tip, which she said will relax patients and make them feel more comfortable about the procedure, Dr. Weinkle highlighted the pharmacology of Botox and how thought about its stability has changed throughout the years.

Fifteen years ago, doctors believed that Botox was stable for only four hours, Dr. Weinkle said. Today, they know that it is stable for up to four, and possibly even six, weeks.

Currently, Botox is only FDA approved for is injection into the glabella, but it’s common for physicians to use it in other areas as well. Dr. Weinkle advised that dermatologists inform their patients that injection to any area other than the glabella is off label. It’s also critical to set realistic expectations with patients and avoid treating too many areas in one sitting (particularly during a first-time visit), she added.

When injecting Botox, Dr. Weinkle indicated that her favorite syringe is the Braun 1cc syringe. She said she prefers a 31-gague needle, "but remember the honing isn’t consistent." If a dermatologist hears "crunching" during injection, the needle is dull and must be changed. Dr. Weinkle also advised physicians not to use a needle for more than four injections before changing it.

When evaluating a patient, dermatologists must consider facial anatomy, Dr. Weinkle said. This means analyzing the face at rest and in movement, as well as noting redundant skin and laxity around the eyes and forehead. This is critical "no matter what toxin comes down the road," she added.

And to master Botox injection, "it’s all about the muscles," Dr. Weinkle said, particularly the "Yin and Yang" of muscles and how they work together. Dermatologists should memorize the muscle map distributed by Allergan. She suggested even adding a copy of the map to patient charts to record exactly how many units of Botox were given where during each visit. That way if a patient returns having loved what was done, you can remember exactly what units were injected and where, she said.

One neurotoxin currently awaiting FDA approval is Reloxin (Medicis), a multihemagglutinin complex that shows to have a 72-hour median time to onset and a median duration of 85 to 117 days. Typical dosing will be 50 to 80 units, and the toxin will be dispensed in 33-unit vials. Thus far, headache has been reported as the main adverse event.

Also down the road is Xeomin (Merz), which is beginning phase three clinical trials soon and is similar to Botox in that they are one-to-one in units. Xeomin lacks hemagglutinin proteins, but Dr. Weinkle said she doesn’t think this will make much difference in its efficacy.

One last treatment that Dr. Weinkle highlighted was the use of Botox for migraine alleviation. Those patients who experience relief from their symptoms as a result of Botox injection return faithfully, she said, adding that she typically injects the glabella, temple and post occipital muscle (5 units both sides) and possibly the pterygoid intraoral muscle as part of her migraine therapy. Dermatologists can use 346.9 as the ICD9 code to bill for this procedure, she said.

Botox is also being used to decrease sebum production, promote wound healing and treat alopecia areata and possibly even rosacea, Dr. Weinkle said. The efficacy of Botox for treating rosacea will be determined down the road, she added. DT

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