Can Your Botox Stop Working? Plus, What To Do If It Does

Have we reached peak neurotoxin injections?

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Young woman gets beauty facial injections in salon

Neurotoxins are hot right now, with over 3.6 million Americans going under the needle in 2021. Fueled in part by increased patient transparency on social media — #Botox has over five billion views on TikTok alone — and medical providers becoming internet celebrities in their own right, our collective interest in immobilizing various facial muscles clearly isn’t going anywhere anytime soon. But as the industry reckons with the potential interactions both the COVID virus and its subsequent vaccines have with the five FDA-approved options currently on the market (including Botox, Jeuveau, Dysport, Xeomin, and Daxxify) there are now more reports that these neurotoxins can simply… stop working.

Don’t panic text your dermatologist just yet though. Like most sensationalist news in the beauty industry, the question of whether or not your Botox is going to wear off before the average three month mark isn’t a simple “yes” or “no” answer. On the contrary, there are plenty of nuances around neurotoxin injections to consider well before you start worrying that you’ll eventually develop immunity to them.

Curious to know more about potential neurotoxin tolerance before your next appointment? Ahead, the experts weigh in on whether or not you’ll one day have to retire your Botox habit altogether.

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What Influences How Someone Reacts To A Neurotoxin?

The first thing to understand when you visit your dermatologist, plastic surgeon, or other licensed healthcare practitioner for cosmetic injectables is that you’ll never receive an identical treatment as the person next to you. That’s because there are a number of factors to consider before the needle ever punctures your skin, including a patient’s “age, the strength of the muscles being treated, dilution of the toxin, and injection placement,” says board-certified dermatologist Dr. Purvisha Patel. All of these things determine how many units (the measurement by which your provider will charge for treatment) you’ll receive, the best brand of neurotoxin to use, and how long your injectable will last.

More units of neurotoxin also mean that the effect will be stronger, but it won’t necessarily last longer. “Because [these neurotoxins] all have different manufacturers they all have slightly different times of wearing off and kicking in,” explains Dr. Shari Marchbein, a New York board-certified dermatologist. “They’re slightly different molecules — some are bound to proteins —and that can all affect the efficacy.”

Although these neurotoxins have a similar function and contain the same active ingredient —botulinum toxin A — the variations between them lie in the formulation. As Dr. Patel explains, “All neurotoxins work my attaching to the SNAP receptor on the muscle to prevent it from contracting. The difference between them is the molecule and the proteins attached.” (Of the five FDA-approved brands that are available in the US market, Xeomin is the only one that does not contain a complexing protein, according to board-certified dermatologist Dr. Michelle Henry.)

Can You Become Immune To Botox Or Another Neurotoxin?

So, for those people who receive Botox or another neurotoxin injections every three to six months (which is the average length of time most medical providers will recommend between treatments), there is, unfortunately, a risk that they will one day not be as effective. “Botox tolerance, also known as Botox resistance, is a phenomenon that can occur in those individuals who develop high enough antibodies against the botulinum toxin,” says Dr. Henry. “The factors that contribute to neutralizing antibody formation against botulinum toxin type A have not been well characterized. The data that does exist suggests that two factors are important: protein load per effective dose (volume) and frequency of exposure.” That means that if you receive injections more frequently or receive a higher dose, these can increase your likelihood of becoming immune to their benefits.

The good news, however, is that this in an extremely rare occurrence according to Dr. Marchbein, who herself developed Botox tolerance over the years. “There are some studies for cosmetic applications, and the incidents that they came up with for neutralizing antibodies was estimated at 0.14%.” But once she switched to a different neurotoxin, in her case Dysport, she was once again able to respond to botulinum toxin A injections, which is true for most patients that develop tolerance to a certain neurotoxin. “In my entire career of 18 years I've only had two patients who who have now failed to respond to the neuromodulators that are commercially available,” she adds.

So while possible, just remember, neurotoxin tolerance is still highly unlikely (although data to support how COVID affects these formulas and how well they work is still lacking at this time). It might just mean switching up your injections brand to keep your facial muscles immobile. Hopefully, in the coming months and years there will be more data about how COVID-19 vaccines impact neuromodulator injections, like this recent study which found that botulinum type A may be marginally less effective post-vaccination.

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How Can You Avoid Neurotoxin Tolerance?

More is not always more when it comes to beauty, and that’s especially true in the case of injectables. But what steps can you take to ensure that your favorite neurotoxin continues to work?

In order to avoid developing neutralizing antibodies, which will render your injections ineffective, it’s crucial to adhere to a treatment schedule that mirrors the rate at which your body metabolizes your choice of injection (again, every three to six months on average). Visiting your provider too frequently puts you at a higher risk of developing neurotoxin tolerance, as will injecting too many units in the hopes that the benefits will last longer (or if you have particularly strong facial muscles).

Dr. Marchbein explains that while patients often aren’t aware of what neurotoxin they’re receiving in their treatments (as your provider will consider multiple factors to determine which formula is right for you), if you’re worried about developing tolerance, perhaps because you need a higher dose for the injections to work, it might be worthwhile to explore two of the five options. “It is possible that there is a reduced risk of tolerance development with Xeomin and Jeuveau as they do not contain a complexing protein, which may be the target of these antibodies,” says Dr. Blair Murphy-Rose, a board-certified cosmetic and medical dermatologist at the Laser & Skin Surgery Center of New York.

There is also some discourse around whether or not vegetarians or vegans can develop neutralizing antibodies faster than other people, but all of the experts reiterated that there is no significant evidence to support this claim. “It’s probably true that those people metabolized it faster,” says Dr. Marchbein, but there is likely no need to alter your plant-based diet for fear of rendering your neurotoxin ineffective.

Overall, it’s always wise to discuss any fears or concerns with your medical provider so that they can suggest an injectable and a schedule that will deliver the results you want appointment after appointment. So don’t spend too much time worrying that your Botox is wearing off — after all, avoiding forehead wrinkles is already half the battle.