I know several people who’ve built up resistance to Botox. Will it happen to me?
Dear Beauty Editor,
I know multiple acquaintances who built up an immunity to Botox, around 15 years or so after they started. They were middle-aged when they started Botox, so they stopped responding in their mid-to-late 50s. But if you start getting Botox at 25, it could very well stop working by 40. So it seems to me you’ve wasted all your years of effectiveness before you actually needed it. What is the risk of building up immunity to the neurotoxin in Botox?
C.M.
I get a lot of questions about Botox — whether it’s necessary, when to start it, if it works on trap muscles — but this is one of the most detailed yet, so we’re going to have to get technical. It sounds like you’re describing Botox resistance, which is when injections of a cosmetic neuromodulator (it could be Botox Cosmetic or another name brand) don’t have the same potency or last as long as they used to. “We know that patients can get antibody formation to neuromodulators, and those antibodies can lead to resistance,” says board-certified dermatologist Melissa K. Levin, M.D. Generally speaking, the incidence is pretty rare. “But it’s hard to give an exact percentage because there are many different types of neuromodulators, and resistance depends on which ones you’re getting and how often you’re getting them.”
I suggest finding an injector you trust and talking to them about your skin concerns — as well as any worries you may have about developing resistance. For me, that person is Levin (she treats me with Botox twice a year). When I brought up your question with her, she explained there are things a good injector can do to minimize the chances of resistance and find a workaround if it happens. Read on for her advice.
Is Botox resistance common?
When we talk about neuromodulators, we often use the generic trademark Botox to refer to all of them, but it’s important to make a distinction between the different types here. There are four neuromodulators commonly used in the United States: Botox Cosmetic (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), Xeomin (incobotulinumtoxinA), and Daxxify (daxibotulinumtoxinA‐lanm). All of them contain botulinum toxin type A, a protein that temporarily blocks nerve signals to muscles, smoothing the appearance of dynamic wrinkles. Levin says Botox Cosmetic and Dysport have a higher protein load than Xeomin or Daxxify, and therefore a higher chance of developing antibodies that can lead to resistance. Still, it’s rare. For example, in one published research analysis, about .5 percent of people injected with onabotulinumtoxinA (Botox Cosmetic) developed antibodies after treatment.
Which neuromodulator is least likely to cause resistance?
There are no definitive studies comparing all the neuromodulators and how people respond over time. However, Levin says that Xeomin is probably the least likely to cause resistance issues. “You can still develop multiple different types of antibodies to it, but there’s a lower chance of resistance than with Botox or Dysport,” she says.
How do you decrease the chance of developing Botox resistance?
“It’s the frequency of injections that affects your immune system’s response more than the volume load,” says Levin. So rather than spacing out a bunch of different types of Botox injections — perhaps getting a Nefertiti neck lift one month, treating frown lines the next, and then deciding to get a lip flip a month after that — Levin suggests getting as many treatments as possible at one time. “I try to clump together my patients’ cosmetic treatments,” says Levin. “This wasn’t as much of an issue years ago, but with the way people get Botox now, it’s something to think about.”
How do you know if you’re resistant to Botox?
There aren’t any commercial tests a doctor can use to check your levels of the multiple different types of antibodies to ingredients in cosmetic neuromodulators. And, to make things even more confusing, even if antibodies are present, resistance wouldn’t happen all at once. “It’s not like you go for an injection one time and it just does nothing,” says Levin. More likely, you may notice that your injections are not lasting as long as they used to or the muscles aren’t as immobilized after treatment. If that happens to you, talk to your provider as soon as possible about what’s going on. A good injector will always take before and after photos of their work, so they’ll have documentation of what’s going on and can talk to you about your options.
What can you do if you’re resistant to Botox?
Levin says depending on which neuromodulator you’ve been getting, your provider might try another brand. Or, if you are still getting some response, they may just have to inject you more frequently. Another possibility is a “wash-out period,” where you don’t use any neuromodulators for at least six months or up to a few years. “In some cases, that can diminish the body’s resistance,” Levin says. But, she adds, most of her patients don’t want to go that long without any type of cosmetic intervention. So that’s when she may talk to them about energy-based treatments such as lasers or skin tightening. “It’s possible we do that and you like it, and then a few years later, the neuromodulator works again.” Or you can always cede control to Mother Nature and discover how great you look when you do nothing at all.
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