In part 2 of our three-parter on cosmetic injectables, we’re turning the spotlight on injectable neurotoxins. These are used to treat wrinkles — that’s the first thing that comes to mind when you hear ‘botox.’ But neurotoxin injections are used for much more than this.
Injecting neurotoxins doesn’t sound like something that would be a growth industry. But as we’ll see, neurotoxin injections have uses outside the aesthetic sector. They’re restoring limb function and even sight, as well as being one of the most effective nonsurgical cosmetic procedures out there.
In this post, we’ll look at what neurotoxins are, what they’re for, and who can administer the injections. It’s a deep dive: at the end, you’ll know all you need to know to see the advantages of adding neurotoxin injections to your scope of practice. Let’s start at the beginning.
What are toxins?
When we’re talking about injectables, neurotoxins are chemicals that change the way nerves transmit information to muscles. One of the most widely used is purified botulinum toxin, and it’s a good case study to understand the others, at least in principle.
Botulinum is a neurotoxin produced by the bacterium Clostridium botulinum and by some related bacteria. In the wild, botulinum neurotoxin can lead to botulism poisoning, a rare but serious disease, causing paralysis of muscles across the body and killing by interrupting cardiorespiratory function. When we inject botulinum toxin for patients, we’re not courting this kind of disaster. We inject controlled doses placed intramuscularly and the effect is local. We’re able to paralyze specific muscles.
Acetylcholine is a chemical messenger used by nerves to communicate with muscles to contract. Botulinum toxin prevents nerves from releasing acetylcholine from their nerve endings. So when we use botulinum in a clinical setting, we’re inducing local, targeted muscle paralysis, temporarily relaxing the muscles.
Why we use toxins
Inducing this kind of paralysis into some muscles lets us alter the patterns of contraction and relaxation in a patient’s face, or in their scalp or back. Muscle contractions control all kinds of things in the body, from the appearance of the skin on the face to degenerative diseases, chronic cramping, pain, and even excessive sweating. So, the fact that we can effectively switch off contractions with neurotoxins is huge for patients.
There’s also a shortage of other drugs that can achieve similar effects. Most available muscle relaxants are systemic, and they often come with undesirable side effects. Antispasmodics like Baclofen can cause pregnancy complications and have a whole-body effect, relaxing all muscles — not just the ones your patient might be having trouble with. Benzodiazepines are also used as muscle relaxants, but they’re sedatives too and can be addictive.
Injectable neurotoxins are highly targetable. You can inject one muscle and not affect the muscle right next door. Low doses can be used because the effect is local, so despite the ‘alarm bell’ feel of the word toxin, they’re safer. And the effect is longer-lasting than other options so people don’t have to see their doctor so often.
Who needs neurotoxins?
Patients who use neurotoxins fall into two groups: those responding to a medical need, and those responding to a cosmetic wish. However, if you’re familiar with dealing with insurance for facial surgery, you’ll know that this isn’t cut and dried. They’re two Venn circles with considerable overlap. If someone has facial asymmetry resulting from an injury and they’d like to use toxins to relax some of their facial muscles so they look more like everyone else and can eat more easily, is their need ‘medical’? It’s not always either-or.
Here are some of the most common uses for toxins:
Botox injections can block the nerve signals that activate sweat glands, reducing excessive sweating from the hands, feet, back, armpits and other parts of the body.
In cerebral palsy, multiple sclerosis, and many other conditions, chronic muscle spasms cause pain and disability. By compressing nerves, they can paradoxically cause referred muscle laxness elsewhere too. Botox injections can relax spasming muscles, alleviating suffering.
Hair loss can be accelerated by restricted blood flow to the scalp, caused by excessively-tight scalp muscles. Botox injections can temporarily paralyze these muscles and allow blood flow to follicles to resume.
Toxins can be used to relax the muscles lying directly under the skin, reducing the appearance of wrinkling, especially in the fine skin over the brows and around the mouth and eyes.
Temporary muscular spasms can cause radiating pain, discomfort, and dysfunction. Botox injections can be used to relax spasming muscles, particularly those involved in cervical dystonia, which can cause the head to turn uncontrollably to one side or to look up or down. Botulinum toxin injections are the treatment of choice for this condition.
Lazy eyes and crossed eyes (amblyopia and strabismus)
A ‘lazy eye’ is an eye in which some of the muscles controlling eye direction are underpowered or don’t engage properly, while the other muscles are comparatively too strong. The result is a gaze in which a person’s eyes don’t look in the same direction. It can be distressing, and cause vision problems and headaches. Crossed eyes are similar, though the cause is slightly different.
While it’s sometimes addressed with corrective eyewear, exercises, and atropine drops to blur vision in the ‘good’ eye, botulinum toxin can also be used to selectively paralyze the over-strong muscles around the eye, helping the weaker ones to take over and become stronger.
Chronic eye twitches can be caused by an overactive nerve to the muscles around the eye; toxin injections are used to ‘quiet’ the nerve and stop the twitch.
Botulinum injections are a common treatment for overactive bladder and urgency incontinence, and it’s usually what a doctor will reach for when exercises and other less invasive therapies have not worked.
Migraines aren’t just a headache. They can be totally debilitating, and some sufferers have multiple migraines in a single month. Though it’s rare, anyone who has migraines more than 15 days a month may benefit from botulinum toxin injections to reduce the frequency of some symptoms and make migraines more manageable.
This list isn’t exhaustive, but it does cover the most common uses of botulinum toxin.
Who can inject neurotoxins?
Who can inject neurotoxins depends on the nature of the treatment, with more invasive or serious treatments typically requiring more supervision and a higher level of professional qualification. It also depends on state laws, which can differ significantly from one state to another.
Here, we’ll give a general overview.
Doctors and physicians
Doctors and physicians can prescribe and administer botox injections in any state.
Physician’s assistants (PA), nurses (RNs), dentists, and nurse practitioners
Other medical professionals can administer botox in some states and not others. Some states will have additional restrictions, permitting certain professionals to administer injections only for certain conditions, or with a registered physician supervising. It’s always best to check state laws.
Side effects of injectable neurotoxins
Botox is relatively safe when it’s performed by an experienced practitioner. Some of the milder, more common side effects of a botox or other botulinum toxin injection include:
- Pain, swelling or bruising at the injection site
- Headache or flu-like symptoms
- Drooping eyelid or eyebrow
- Dry eyes or excessive tearing
These are relatively mild and though not common, they are not cause for immediate concern.
However, in some patients, botox injections can spread from the injection site through tissues to other areas of the body. It’s rare, but these side effects are more serious and require medical attention:
- Muscle weakness
- Vision problems
- Trouble speaking or swallowing
- Breathing problems
- Loss of bladder control
Again, these side effects are rare. It’s good to advise patients against using botulinum toxin if they’re pregnant or breastfeeding, and these injections are contraindicated for those allergic to casein and whey.
In addition, it’s important to manage patient expectations about neurotoxin injections: they ‘stun’ nerves, rather than killing them or reducing their activity permanently. Botulinum toxin injections need to be repeated, usually every 4 to 6 months, to maintain effects.
Why should you add injecting neurotoxins to your scope of practice?
Some of the use cases we’ve discussed here aren’t available to all practitioners: performing neurotoxin injections into the bladder lining is only really an option for doctors, because of the complexity of the procedure. But cosmetic and some other injection uses are more accessible.
As patients come to expect a broader range of aesthetic procedures and start to see them as part of a holistic approach to well-being, offering neurotoxin injections can make your practice more appealing, improve patient loyalty, and fit synergistically with other treatments you offer.
If you’re following our three-part series on cosmetic injectables, stay tuned: the third one is in the pipeline. (We’ll be focusing on fillers in part 3.) If you missed the first one, you can read it here.