Navigating Neuromodulators in 2025

In a Dermatology Week 2025 session titled “Choosing a Neuromodulator in 2025,” Deirdre Hooper, MD, offered attendees a masterclass in both the science and strategy behind botulinum toxin selection. With 6 US Food and Drug Administration (FDA)-approved neuromodulators now available, Dr Hooper emphasized that while all are effective and safe, they are not interchangeable—a key takeaway for clinicians looking to optimize results and patient satisfaction.

Dr Hooper opened with a historical lens, tracing the origins of botulinum toxin from 19th-century Germany to its emergence as both a weaponized agent and therapeutic breakthrough. This foundation helped underscore the complex manufacturing processes and scientific nuances that differentiate today’s commercial products.

“All of these products are botulinum toxin type A,” she explained, “but differences in strain, purification, excipients, and potency assays make each one unique.”

A central focus of the talk was the manufacturing process, which plays a significant role in how the final product behaves clinically. For instance, some neuromodulators contain neurotoxin-associated proteins while others, like INCO and DAXI, do not, potentially impacting immunogenicity and duration.

“Potency is measured in units, but each company uses a different proprietary assay to define a ‘unit,’” said Dr Hooper. “This means 20 units of 1 product are not necessarily equivalent to 20 units of another.”

She reviewed the 6 currently available toxins—onabotulinumtoxinA (Botox), incobotulinumtoxinA (Xeomin), abobotulinumtoxinA (Dysport), prabotulinumtoxinA (Jeuveau), daxibotulinumtoxinA-lanm (Daxxify), and letibotulinumtoxinA—and discussed their unique features, including excipients, vial size, reconstitution guidelines, and FDA indications.

From a practical standpoint, Dr Hooper shared pearls on reconstitution, storage, and diffusion, noting that “spread is more a function of dose and dilution than inherent product differences.” For example, higher reconstitution volumes can create a more natural appearance but may reduce precision.

She also addressed immunogenicity, a concern as cumulative exposure increases. “Neutralizing antibodies are rare, but when they occur, they can cause secondary non-response,” she said. While data are still limited, INCO may carry a lower risk due to its lack of accessory proteins.

When choosing a neuromodulator for clinical practice, Dr Hooper urged providers to consider not only efficacy and patient outcomes, but also logistical factors: cost per vial, storage requirements, staff training, and the potential for brand partnerships with companies offering fillers or skin care products.

Ultimately, she concluded, “All the products work, but your choice should be based on the science and what fits best into your practice.”

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Reference
Hooper D. Choosing a neuromodulator in 2025. Presented at: Dermatology Week; May 14–16, 2025; Virtual.