Now that there is a second type A botulinum toxin on the block in the United States, it is important to understand the differences between them, as it will be for other type A toxins poised to follow. On April 29th, the FDA approved Dysport, the second type A botulinum toxin for use in the United States. With this approval, there are now two toxins that can be injected by physicians. While there are many similarities between the two agents, there are also important differences, and it behooves all injectors to understand what is and what is not significantly different with each. What’s more, as the market becomes more crowded with the advent of other type A toxins, such as Xeomin (Merz) and PurTox (Mentor/Johnson & Johnson), the similarities and differences between the products will become even more complicated.
What’s the Same
The most important similarity between Botox and Dysport is the fact that both are type A toxins. Unlike the other toxins in the botulinum family — there are seven — these two have similar structures. In both Dysport and Botox, the heavy chains of the molecules are responsible for binding the cell membrane and the light chains are responsible for cleaving the SNAP 25 proteins, thereby blocking the release of the acetylcholine vesicle to the cellular membrane. It is this inhibition that blocks communication between the nerve and the muscle that causes relaxation and clinical improvements. This SNAP 25 cleavage is also the key to inhibition of acetylcholine stimulated sweating.
What’s Different
Diffusion Ratios — Among the differences between the two molecules are the diffusion ratios. This is clinically relevant because it may (or may not) be important for complications such as ptosis as well as for efficacy halos that deliver subtle treatment differences. Although some publications have demonstrated differences in the distribution of products, the exact diffusion profiles are controversial. Hexsel et al1 demonstrated a wide diffusion ratio with both Botox and Dysport. Interestingly, when the Dysport: Botox ratio was 2.5:1, the diffusion halo of both products was statistically similar according to these authors. What happens in clinical practice when physicians use volumes different from those in the package insert remains to be seen, but as with existing products, the diffusion halo depends largely on the dilution and volume of fluid used by the individual physician. Ratio of Activity — The ratio of activity for the two products may vary depending on the experience of the author in the journal article read, but most practitioners familiar with both products advise using a ratio of 2.5 to 3 units of Dysport to each unit of Botox. This is important, because it is likely that some injectors will have issues because there is potential for substitution without compensation. Initially — especially with those injectors who are dabbling or who lack the training to understand the differences — this may result in the belief among patients who are underdosed with Dysport that the product “doesn’t work,” when in fact the fault may lie not with the product but injectors who are not trained correctly and substitute using a unit-per-unit dose.
Dysport Injection Considerations
Glabella The injection technique for Dysport treatment of the glabella is familiar. It is composed of five injections, with two each into the corrugators and one into the procerus. When injecting the corrugators, the physician should stay at least 1 cm superior to the orbital rim. Following injection of Dysport, patients in the pivotal FDA registration trial for treatment of the glabella noted onset in 2 to 3 days. Other Areas Injections of Dysport into other areas including the frontalis, mentalis, platysma and orbicularis also mirror injections of other toxins with an adjusted dosage. Volumes injected will probably be different than volumes used for other toxins when the recommended dilution is used. However, this depends on the dilution preference of the given injector and both products will likely be used in a manner other than that on the package insert. Platysma injections will need between 75 and 200 units of Dysport to relax the bands. Injections should be spread out over the bands and placed directly into the muscle while grasping it between two fingers. As with Botox, underdosing is better than overdosing, and one may expect that at some point there may be reports of dysphagia associated with excessive dosing or placement that is too deep. Hyperhidrosis will require about 300 units to treat both axilla of the average individual patient. Using iodine and starch to outline the areas of sweat will help define where to inject. Palmar and plantar hyperhidrosis may also be treated with Dysport.
MEDICAL APPLICATIONS
Although as dermatologists, we typically don’t treat patients with headaches or neck spasms, it is likely that many patients who initially come to us for cosmetic indications will migrate to functional treatments and vice versa. Neck Spasms To treat neck spasms with Dysport, the dose required may be significantly higher than doses used for cosmetic treatments. However, I inject the scalenes and trapezius muscles with about 100 units of Botox in a given session (preferring to err on the side of caution) and I would expect that injections with Dysport will utilize about 300 units. Headaches As with the discovery that cosmetic benefits accrued to patients treated for diplopia, many patients treated for glabellar rhytids have observed improvements in headaches with Botox treatment. In my practice, many patients who initiated toxin treatment for cosmetic reasons now come primarily for relief from headaches. It is likely that treatment with Dysport for frontalis and glabellar rhytids will uncover migraine patients who find relief from this modality. Estimated doses for the treatment of frontal headaches is from 75 to 150 units of Dysport. Headaches emanating from temporal regions may be treated with similar doses of Dysport (split between the two sides). Headaches and temporomandibular disorder that are the result of grinding should be treated with injections into the masseter, and doses for this location should begin with about 45 units into each side.
PATIENT SELECTION
Which toxin is right for which patient is a question that will be resolved over the next few years much as the markets, physicians and patients have sorted out the filler markets. My expectation is that more people will seek treatment with toxins because both companies will raise awareness with direct-to-consumer advertising. Ultimately the decision on which products to use will largely be determined by clinical trials and pricing. It is likely that one of the companies will have some price advantage that will be a selling point for patients who are price sensitive in a challenging economic environment. Patients who want a quicker onset will be attracted to the product with a 1- to 2- day onset. “Virgin patients” — those without preconceptions or preferences — will most likely ask their physicians to help them decide which product is right for them. Dr. Beer is in private practice in West Palm Beach, FL. He’s also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University, and Director of The Cosmetic Boot Camp meeting. Disclosures: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for 3M, Bioform Medical, Lumenis, Medicis, Sanofi Aventis, Solta Lasers and Stiefel.
Now that there is a second type A botulinum toxin on the block in the United States, it is important to understand the differences between them, as it will be for other type A toxins poised to follow. On April 29th, the FDA approved Dysport, the second type A botulinum toxin for use in the United States. With this approval, there are now two toxins that can be injected by physicians. While there are many similarities between the two agents, there are also important differences, and it behooves all injectors to understand what is and what is not significantly different with each. What’s more, as the market becomes more crowded with the advent of other type A toxins, such as Xeomin (Merz) and PurTox (Mentor/Johnson & Johnson), the similarities and differences between the products will become even more complicated.
What’s the Same
The most important similarity between Botox and Dysport is the fact that both are type A toxins. Unlike the other toxins in the botulinum family — there are seven — these two have similar structures. In both Dysport and Botox, the heavy chains of the molecules are responsible for binding the cell membrane and the light chains are responsible for cleaving the SNAP 25 proteins, thereby blocking the release of the acetylcholine vesicle to the cellular membrane. It is this inhibition that blocks communication between the nerve and the muscle that causes relaxation and clinical improvements. This SNAP 25 cleavage is also the key to inhibition of acetylcholine stimulated sweating.
What’s Different
Diffusion Ratios — Among the differences between the two molecules are the diffusion ratios. This is clinically relevant because it may (or may not) be important for complications such as ptosis as well as for efficacy halos that deliver subtle treatment differences. Although some publications have demonstrated differences in the distribution of products, the exact diffusion profiles are controversial. Hexsel et al1 demonstrated a wide diffusion ratio with both Botox and Dysport. Interestingly, when the Dysport: Botox ratio was 2.5:1, the diffusion halo of both products was statistically similar according to these authors. What happens in clinical practice when physicians use volumes different from those in the package insert remains to be seen, but as with existing products, the diffusion halo depends largely on the dilution and volume of fluid used by the individual physician. Ratio of Activity — The ratio of activity for the two products may vary depending on the experience of the author in the journal article read, but most practitioners familiar with both products advise using a ratio of 2.5 to 3 units of Dysport to each unit of Botox. This is important, because it is likely that some injectors will have issues because there is potential for substitution without compensation. Initially — especially with those injectors who are dabbling or who lack the training to understand the differences — this may result in the belief among patients who are underdosed with Dysport that the product “doesn’t work,” when in fact the fault may lie not with the product but injectors who are not trained correctly and substitute using a unit-per-unit dose.
Dysport Injection Considerations
Glabella The injection technique for Dysport treatment of the glabella is familiar. It is composed of five injections, with two each into the corrugators and one into the procerus. When injecting the corrugators, the physician should stay at least 1 cm superior to the orbital rim. Following injection of Dysport, patients in the pivotal FDA registration trial for treatment of the glabella noted onset in 2 to 3 days. Other Areas Injections of Dysport into other areas including the frontalis, mentalis, platysma and orbicularis also mirror injections of other toxins with an adjusted dosage. Volumes injected will probably be different than volumes used for other toxins when the recommended dilution is used. However, this depends on the dilution preference of the given injector and both products will likely be used in a manner other than that on the package insert. Platysma injections will need between 75 and 200 units of Dysport to relax the bands. Injections should be spread out over the bands and placed directly into the muscle while grasping it between two fingers. As with Botox, underdosing is better than overdosing, and one may expect that at some point there may be reports of dysphagia associated with excessive dosing or placement that is too deep. Hyperhidrosis will require about 300 units to treat both axilla of the average individual patient. Using iodine and starch to outline the areas of sweat will help define where to inject. Palmar and plantar hyperhidrosis may also be treated with Dysport.
MEDICAL APPLICATIONS
Although as dermatologists, we typically don’t treat patients with headaches or neck spasms, it is likely that many patients who initially come to us for cosmetic indications will migrate to functional treatments and vice versa. Neck Spasms To treat neck spasms with Dysport, the dose required may be significantly higher than doses used for cosmetic treatments. However, I inject the scalenes and trapezius muscles with about 100 units of Botox in a given session (preferring to err on the side of caution) and I would expect that injections with Dysport will utilize about 300 units. Headaches As with the discovery that cosmetic benefits accrued to patients treated for diplopia, many patients treated for glabellar rhytids have observed improvements in headaches with Botox treatment. In my practice, many patients who initiated toxin treatment for cosmetic reasons now come primarily for relief from headaches. It is likely that treatment with Dysport for frontalis and glabellar rhytids will uncover migraine patients who find relief from this modality. Estimated doses for the treatment of frontal headaches is from 75 to 150 units of Dysport. Headaches emanating from temporal regions may be treated with similar doses of Dysport (split between the two sides). Headaches and temporomandibular disorder that are the result of grinding should be treated with injections into the masseter, and doses for this location should begin with about 45 units into each side.
PATIENT SELECTION
Which toxin is right for which patient is a question that will be resolved over the next few years much as the markets, physicians and patients have sorted out the filler markets. My expectation is that more people will seek treatment with toxins because both companies will raise awareness with direct-to-consumer advertising. Ultimately the decision on which products to use will largely be determined by clinical trials and pricing. It is likely that one of the companies will have some price advantage that will be a selling point for patients who are price sensitive in a challenging economic environment. Patients who want a quicker onset will be attracted to the product with a 1- to 2- day onset. “Virgin patients” — those without preconceptions or preferences — will most likely ask their physicians to help them decide which product is right for them. Dr. Beer is in private practice in West Palm Beach, FL. He’s also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University, and Director of The Cosmetic Boot Camp meeting. Disclosures: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for 3M, Bioform Medical, Lumenis, Medicis, Sanofi Aventis, Solta Lasers and Stiefel.
Now that there is a second type A botulinum toxin on the block in the United States, it is important to understand the differences between them, as it will be for other type A toxins poised to follow. On April 29th, the FDA approved Dysport, the second type A botulinum toxin for use in the United States. With this approval, there are now two toxins that can be injected by physicians. While there are many similarities between the two agents, there are also important differences, and it behooves all injectors to understand what is and what is not significantly different with each. What’s more, as the market becomes more crowded with the advent of other type A toxins, such as Xeomin (Merz) and PurTox (Mentor/Johnson & Johnson), the similarities and differences between the products will become even more complicated.
What’s the Same
The most important similarity between Botox and Dysport is the fact that both are type A toxins. Unlike the other toxins in the botulinum family — there are seven — these two have similar structures. In both Dysport and Botox, the heavy chains of the molecules are responsible for binding the cell membrane and the light chains are responsible for cleaving the SNAP 25 proteins, thereby blocking the release of the acetylcholine vesicle to the cellular membrane. It is this inhibition that blocks communication between the nerve and the muscle that causes relaxation and clinical improvements. This SNAP 25 cleavage is also the key to inhibition of acetylcholine stimulated sweating.
What’s Different
Diffusion Ratios — Among the differences between the two molecules are the diffusion ratios. This is clinically relevant because it may (or may not) be important for complications such as ptosis as well as for efficacy halos that deliver subtle treatment differences. Although some publications have demonstrated differences in the distribution of products, the exact diffusion profiles are controversial. Hexsel et al1 demonstrated a wide diffusion ratio with both Botox and Dysport. Interestingly, when the Dysport: Botox ratio was 2.5:1, the diffusion halo of both products was statistically similar according to these authors. What happens in clinical practice when physicians use volumes different from those in the package insert remains to be seen, but as with existing products, the diffusion halo depends largely on the dilution and volume of fluid used by the individual physician. Ratio of Activity — The ratio of activity for the two products may vary depending on the experience of the author in the journal article read, but most practitioners familiar with both products advise using a ratio of 2.5 to 3 units of Dysport to each unit of Botox. This is important, because it is likely that some injectors will have issues because there is potential for substitution without compensation. Initially — especially with those injectors who are dabbling or who lack the training to understand the differences — this may result in the belief among patients who are underdosed with Dysport that the product “doesn’t work,” when in fact the fault may lie not with the product but injectors who are not trained correctly and substitute using a unit-per-unit dose.
Dysport Injection Considerations
Glabella The injection technique for Dysport treatment of the glabella is familiar. It is composed of five injections, with two each into the corrugators and one into the procerus. When injecting the corrugators, the physician should stay at least 1 cm superior to the orbital rim. Following injection of Dysport, patients in the pivotal FDA registration trial for treatment of the glabella noted onset in 2 to 3 days. Other Areas Injections of Dysport into other areas including the frontalis, mentalis, platysma and orbicularis also mirror injections of other toxins with an adjusted dosage. Volumes injected will probably be different than volumes used for other toxins when the recommended dilution is used. However, this depends on the dilution preference of the given injector and both products will likely be used in a manner other than that on the package insert. Platysma injections will need between 75 and 200 units of Dysport to relax the bands. Injections should be spread out over the bands and placed directly into the muscle while grasping it between two fingers. As with Botox, underdosing is better than overdosing, and one may expect that at some point there may be reports of dysphagia associated with excessive dosing or placement that is too deep. Hyperhidrosis will require about 300 units to treat both axilla of the average individual patient. Using iodine and starch to outline the areas of sweat will help define where to inject. Palmar and plantar hyperhidrosis may also be treated with Dysport.
MEDICAL APPLICATIONS
Although as dermatologists, we typically don’t treat patients with headaches or neck spasms, it is likely that many patients who initially come to us for cosmetic indications will migrate to functional treatments and vice versa. Neck Spasms To treat neck spasms with Dysport, the dose required may be significantly higher than doses used for cosmetic treatments. However, I inject the scalenes and trapezius muscles with about 100 units of Botox in a given session (preferring to err on the side of caution) and I would expect that injections with Dysport will utilize about 300 units. Headaches As with the discovery that cosmetic benefits accrued to patients treated for diplopia, many patients treated for glabellar rhytids have observed improvements in headaches with Botox treatment. In my practice, many patients who initiated toxin treatment for cosmetic reasons now come primarily for relief from headaches. It is likely that treatment with Dysport for frontalis and glabellar rhytids will uncover migraine patients who find relief from this modality. Estimated doses for the treatment of frontal headaches is from 75 to 150 units of Dysport. Headaches emanating from temporal regions may be treated with similar doses of Dysport (split between the two sides). Headaches and temporomandibular disorder that are the result of grinding should be treated with injections into the masseter, and doses for this location should begin with about 45 units into each side.
PATIENT SELECTION
Which toxin is right for which patient is a question that will be resolved over the next few years much as the markets, physicians and patients have sorted out the filler markets. My expectation is that more people will seek treatment with toxins because both companies will raise awareness with direct-to-consumer advertising. Ultimately the decision on which products to use will largely be determined by clinical trials and pricing. It is likely that one of the companies will have some price advantage that will be a selling point for patients who are price sensitive in a challenging economic environment. Patients who want a quicker onset will be attracted to the product with a 1- to 2- day onset. “Virgin patients” — those without preconceptions or preferences — will most likely ask their physicians to help them decide which product is right for them. Dr. Beer is in private practice in West Palm Beach, FL. He’s also a Volunteer Clinical Instructor in Dermatology at the University of Miami, a Consulting Associate in the Department of Medicine at Duke University, and Director of The Cosmetic Boot Camp meeting. Disclosures: Dr. Beer is an owner of Theraplex LLC, and consults, speaks or performs clinical trials for 3M, Bioform Medical, Lumenis, Medicis, Sanofi Aventis, Solta Lasers and Stiefel.
