Beyond the Science: Botulinum Toxins in the Practice Setting

As interest continues to swell for the new botulinum toxin, here are practical tips and considerations for integrating it into practice.

By Joel Schlessinger, MD
 

The recent addition of Dysport (abobotulinumtoxin A, Medicis) to the current platform of facial aesthetics has generated great interest with both patients and physicians. Since its emergence on the market, physicians have been abuzz, discussing how Dysport differs from Botox Cosmetic (onabotulinumtoxin A, Allergan) and how it expands the potential of botulinum toxin products. Now that Dysport has been on the market for more than six months, dermatologists should be thinking about the practical details of Dysport and how to appropriate it into practice. This includes marketing considerations, as well as reflection on how it impacts the practice of cosmetic dermatology.

Forming a Brand
As the cosmetic market has grown to include a variety of treatments and products, botulinum toxin procedures have remained durable and popular in one form. For years, Botox has stood alone as the premiere botulinum toxin product, during which time it has come to be known as one of the most reliable and consistent treatments in the field. Since Botox had cemented itself as the only botulinum toxin on the market, its name has become synonymous with botulinum injection procedures. Like Coke, Kleenex, and Tupperware, the name Botox has entered the cultural vernacular. It is still one of the most popular cosmetic procedures, no doubt aided by wide brand recognition.

The only downside to such sweeping popularity is that Botox has become a lightning rod for criticism by some people who don't understand the huge benefits it holds. This does not change the fact that many consumers often migrate to the market leader, but it also establishes a subset of individuals who would never consider Botox because of their associations with name. In that sense, Dysport may provide clinicians with more than just another option for patients to consider. Its very presence allows physicians to maneuver more effectively in the patient consultation phase. I have observed that many patients who are resistant to the idea of such a procedure and would likely never receive a Botox injection are surprisingly open to hearing about Dysport.

Importantly, I do not intend to suggest that Dysport is in any way superior to Botox or that physicians should present it that way to patients. Both drugs are excellent, as I will discuss later in the article. But in terms of communicating with patients and informing them about the variety of options cosmetic dermatology offers, Dysport provides an important alternative that may create a range of possibilities for bringing more patients into the realm of cosmetic procedures.

Apart from the subset of patients resistant to the very notion of Botox, there is also a subset of patients who like and enjoy the benefits of Botox, but for whatever reason are not experiencing enough of the effects. This can happen in some cases, such as in patients with larger foreheads or treatment areas. In other cases, results may simply be different than expected, with less longevity than desired. Dysport can address both of these issues, as it appears to provide consistent and long-term results, while impacting a larger field of effect or spread. The downside to Dysport's potency may be in individuals who have the potential for brow ptosis and haven’t ever had effects past the glabella when they were treated with Botox in a limited pattern of injections. On the other hand, I have also found that Dysport is great for younger patients seeking a “smoother” look.

More generally, Dysport gives clinicians the opportunity to re-invigorate patients who may have forgotten about or may not be aware of the benefits that botulinum toxin products have to offer. Another downside to the popularity of Botox is that consumers may be used to the term and some are no longer “excited” about having Botox injections. These individuals are not so much resistant to the idea of a botulinum toxin procedure, but indifferent to it. Therefore, from a marketing perspective, the addition of Dysport opens a number of possibilities to gain the attention of patients about both available botulinum toxin products.

Beyond the marketing and consultation techniques, Dysport also offers advantages that may interest patients who may not have been interested in Botox. Dysport may appeal to patients initially on the grounds that it is relatively cost-efficient. But beyond this, the clinical trials have highlighted other important areas that may interest patients. First, its onset of action has been observed to be quite rapid. In some cases, onset of action occurred around three days after injection, versus seven days with Botox.

Additionally, Dysport's longer cycle of activity provides significant benefit. Some patients may not want to commit to receiving injections every three months, which is commonplace for Botox. But since this can range depending on the patient, I will often tell them that injections are required “every three months or so,” which leaves open the possibility of that extra time but well establishes that three months is standard. With Dysport, I often tell patients they will need another treatment “in three or four months, maybe longer.” In clinical trials, many patients, particularly those who began receiving injections at a younger age, saw the effects of Dysport last longer than 120 days, sometimes even up to 180 days or longer. This will not occur with all or even most patients, but it is encouraging to see such long-lasting effects, even in a particular subset of patients.

In addition, the rate of incidents and adverse events was very low in clinical trials. In particular, rates of ptosis were extremely low or, at the very least, comparable to Botox, which suggests that Dysport is both safe and effective. These points are all important to mention if patients indicate interest in the procedure.

A Changing Landscape
Comparisons between Botox and Dysport are limited only to observations one can make based on clinical experience with both. But since we've had Dysport for a relatively short time in the US, we are still discovering its nuances. Importantly, as we learn more about Dysport, our learning curve for Botox will progress, too. That's because as we learn how they differ, we will better understand how their mechanisms of action help us to achieve specific effects. My clinical experience with Dysport involves over 1,500 patient injections over a period of five years, so my level of comfort is greater than most, if not all, US-based clinicians. The addition of Dysport is perhaps akin to the blossoming market for dermal fillers. Now that we have a variety of fillers, we have learned more about each individual filler and how it situates within the larger spectrum of fillers. Even when we compare fillers that are categorized as the same type, e.g. hyaluronic acids such as Restylane and Perlane, we learn a great deal about each filler by seeing how they differ and complement each other in those differences. As clinicians gain more experience, they can identify areas and opportunities for greater knowledge and use of botulinum toxins. Additionally, from an educational perspective, Dysport has significantly impacted the field, because it has allowed physicians to approach botulinum toxins from a different vantage point. With great analysis and evaluation, we will hopefully learn more about these products and continue to push ourselves in maximizing their benefits.

The available data is essential to understanding these agents, but clinicians learn almost inherently once they begin to experiment and work with the products in a clinical setting. Then the process of product selection is more natural for clinicians.

Even as physicians gain more familiarity with botulinum toxin products, a new safety warning is evidence that we still have much to learn about them. In the very same month that the FDA approved Dysport (April 2009), the FDA also released new safety information regarding all botulinum toxins. New boxed warnings have been added to botulinum toxin products cautioning prescribers that the effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism. These warnings alert clinicians to the importance of considering adverse events when using these products. Although the warnings themselves are worthy of attention, a great deal of misinformation about botulinum toxin products exists and is circulated among the public. This can be a problem, but it is also an opportunity for clinicians to determine the validity of the claims made about these agents and educate consumers and patients.

Ultimately, the delineation of risks is a good thing for dermatology and cosmetic surgery, but only if we diligently inform our patients that the published warnings referrenced patients being treated with large doses of botulinum toxins in areas that are significantly different than typical cosmetic areas of injection. Additionally, it is important for us to remember that these warnings are a class-wide warning and not limited to one product only.

Healthy Competition
Over the last year, cosmetic dermatology has suffered due to the downturn in the economy. Some patients were looking for reasons to avoid cosmetic procedures, which has made marketing efforts more difficult. In light of these factors, Dysport has provided us with the opportunity to reach out to potentially inactive patients and generate more interest in cosmetic procedures in general. Great excitement has been generated amongst cosmetic dermatologists as a result of Dysport, but I have found that consumers, too, have shown great interest in botulinum toxin injections in general.

It will be some time before we have a clearer portrait of the exact differences between Botox and Dysport in terms of their clinical effects. There is a good amount of research on each of them, individually, but it's most important for physicians practicing cosmetic dermatology to familiarize themselves with Dysport and experiment with it. The injection techniques are the same as for Botox, and the clinical trials provide ample information regarding the best candidates for therapy and how to maximize the effect of the drug.

While great emphasis has been placed on the differences between these drugs, it's important to note that having options is good for both agents. In the end, as more physicians get to know Dysport and introduce it to patients, we will begin to understand more clearly that these agents complement each other. Most importantly, giving patients options will serve to benefit all parties.

Dr. Schlessinger has adapted this article from materials prepared for presentation at the Cosmetic Surgery Forum 2009. To learn more about this topic or for more information on the meeting, visit CosmeticSurgeryForum.com.

Dr. Schlessinger has served as a researcher and consultant for Allergan, Medicis, Mentor, and Obagi, and as a researcher for Merz.

 

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About Practical Dermatology

Practical Dermatology is the monthly publication that provides coverage of medical care, cosmetic advancements, and practice management for clinicians in the field. With straight-forward, how-to advice from experts in various fields, we strive to enhance quality of care and improve the daily operation of dermatology practices.