Botulinum toxin, commonly shortened to Botox, is used for several reasons. Some choose to seek Botox treatment for cosmetic purposes, such as wrinkles and face shape, while others receive treatment for various conditions. An important factor in deciding to get Botox is fully understanding how it works, its uses, patient history, and potential risks.
How it Works
Botulinum toxin is one of the most toxic poisons. Botox works by temporarily preventing a muscle from moving and is the most common cosmetic procedure worldwide . An estimate of 3 million people per year receive Botox treatment. The chemical blocks signals from nerves that cause muscle contraction. For example, relaxing facial muscles around the eyes will prevent further wrinkles, like crow's feet. For cosmetic purposes, Botox is most
commonly used for the former, as well as preventing wrinkles on the forehead. Botox treatments are generally safe, and serious side effects are rare with proper use.
How it is Done
Most patients do not feel pain during Botox treatment. Doctors may offer various methods of numbing the area, such as topical anesthesia. A thin needle is used to inject the Botox into the skin or muscle. A doctor decides the number of injections based on the area, treatment purposes, and patient goals. Patients may return to normal activities right after their procedure .
As for health concerns and physical conditions, Botox is most commonly used to treat the following :
● Cervical dystonia (involuntary neck muscle contractions)
● Lazy eye
● Muscle contractures (neurological conditions like cerebral palsy)
● Hyperhidrosis (excessive sweating)
● Chronic migraine (more than 15 days a month)
● Bladder dysfunction
● Eye twitching
Importance of Patient History Review
Most negative reactions to Botox can be prevented by reviewing patient history. This is why talking to a doctor about any health issues before receiving Botox is crucial. Some may be allergic to Botox, and it is recommended that those who are allergic to cow's milk protein do not receive treatment . It should not be injected into infected skin or areas with psoriasis or eczema . Botox is not recommended to those who are breastfeeding, using contraceptives, or pregnant.
Communicating with Healthcare Providers
Honesty between the healthcare provider and patient is important for successful results. Patients should tell their doctor if they have had any other Botox injections in the past four months and if they take muscle relaxants, sleeping aids, allergy medications, or blood thinners . Following the doctor's orders is also crucial to successful treatment. It is recommended that patients do not rub or massage the area for 24 hours after the procedure to prevent the toxin from spreading .
With any medical procedure, there are potential risks. Although many risks can be prevented with proper care and patient history review, it is important to understand the possible dangers of Botox. Side effects can be separated into two categories: transient and benign side effects and serious adverse effects .
Transient and Benign Side Effects
These side effects of Botox are usually at or near the treated area and treatable, resolving in a few days. Patients may experience ecchymosis (skin discoloration caused by blood under the skin) or bruise at the injection site . A more severe effect is a hematoma, a severe bruise that collects blood under the skin. In most cases, abscess formation due to hematomas is effectively prevented with antibiotics . The hematoma itself may be treated with pressure and ice packs. Pain is also common at the injection site. Topical creams may be used to minimize pain and numb the area while healing. Temporary dry skin and flakiness may also occur which could cause pain .
Although rare, infection at the injection site is a risk with Botox treatment. To avoid this, the injection site should be thoroughly cleaned, and any contamination should be avoided. It is recommended that after Botox, patients should not touch the area until healed . Antibiotics may also be prescribed to prevent an abscess from forming and leaving a possible scar.
Headache is also a common side effect. This is caused by the toxin initiating muscle spasms and paralysis, in most cases, briefly. The general stress of the injection and the idea of a procedure may also cause a headache for some . Headaches and hypoesthesia (decreased sense of touch and sensation) commonly last for 24-48 hours after treatment. Patients may experience dry mouth and mild malaise (general discomfort). In some cases, Botox can cause allergic reactions, which can range from mild to severe. Many reactions can be prevented by analyzing patient history, as well .
Serious Adverse Effects
The FDA describes serious adverse effects as "a life-threatening experience requiring intervention to prevent permanent damage and associated with patient hospitalization or prolongation of existing hospitalization, and persistent or significant disability," . It is important to note that serious side effects are 33 times higher for therapeutic than cosmetic Botox. Some cosmetic uses of Botox may require larger doses, possibly leading to an increased risk of serious harm . Botox can spread 30-45 mm from the injected muscles, which can cause accidental paralysis in undesired areas resulting in serious side effects. With professional care, many of these side effects are avoidable, making it very important to select a doctor carefully . After cosmetic or treatment use, serious side effects include muscle weakness, dysphagia, and allergic reactions.
Muscle weakness is the most common serious side effect of Botox. This and general weakness can happen at and around the injection site. The symptoms surrounding muscle weakness, such as dysarthria (speech disorder), dysphonia (difficulty speaking), dysphagia (difficulty swallowing), and respiratory arrest (one stops breathing), are known as botulism . At first, these symptoms can present most commonly a year after the first injection as headache and fatigue. These headaches may be prolonged, as up to 1% of patients have severe, debilitating headaches.
Neck muscles are especially prone to the spread of Botox, which causes dysphagia to be one of the most common serious side effects. Dysphagia usually occurs around 9.7 days after Botox treatment and lasts on average 3.5 weeks . In more severe cases, a temporary soft diet change may be prescribed.
The most serious allergic reaction, anaphylactic shock, may happen after receiving Botox. Those who receive treatment for therapeutic and cosmetic purposes have the same risk of developing an allergic reaction. The severity may be curbed by medications, such as epinephrine and methylprednisolone. Hypersensitivity to Botox can occur with repeated injections, which causes the formation of antibodies against the Botox toxin . Longer duration of treatment, shorter intervals between injections, large doses, and preparation of Botox can cause the formation of these antibodies. Less than 1% of treatments will experience antibodies. In most cases, Botox treatment for cosmetic or therapeutic reasoning is safe. Patients should take time to think about their procedure. By understanding how Botox works and its common uses, analyzing patient history with a trusted doctor, and being aware of potential risks, Botox can be very successful while harm can be minimized.
1. Mayo Foundation for Medical Education and Research. (2021, February 2). Botox injections. Mayo Clinic.
2. Althawadi, N., Ujam, A., & Visavadia, B. (2022, February 25). Botox hidden dangers. Nature News. Retrieved April 27, 2022, from https://www.nature.com/articles/s41415-022-4006-3.
3. Witmanowski, H., & Błochowiak, K. (2020, December). The whole truth about botulinum toxin - A Review. Postepy dermatologii i alergologii. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874868/.
Author: Sophie Gangi
Editor: Terin Buckley
Health scientist: Dora Sow