Resumo

Objectives: This study aims to analyse, discuss and propose changes to the approach and selection of BonTa formulations for cosmetic neurotoxin application, by analysing a case of a patient who developed tolerance and complete lack of clinical response to BonTa treatments, and subsequent literature review regarding this growing clinical concern and associated consequences Introduction: The use of BonTa formulations for cosmetics purposes is a continuous growing application. Formulations containing complexing proteins that are used to stabilize the core neurotoxin allowing it’s commercial application have been associated with the development of neutralizing antibodies, which seem to translate to the core neurotoxin, making any types of BonTa ineffective in such a given patient. This translates also to the lack of results on the future need of BonTa treatments for therapeutic applications, which may be of significant detriment to patient’s health. Materials / method: We have accompanied a case of a patient that was treated by myself since 2019 with abobotulinumtoxinA who became a non responder following a period of seeing a different practitioner and seeing me again in 2024 reporting the other practitioner dose or technique was inadequate and was having no response. The patient was subsequently treated by myself with abobotulinumtoxinA, IncobotulinumtoxinA and then again 2 weeks later with RelabotulinumtoxinA, all resulting in inadequate clinical outcomes, indicating the formation of ABs. A literature review was performed re non responder and NABs. Results: The progressive lack of response following treatments with abobotulinumtoxinA , and subsequent confirmation of lack of effectiveness across multiple botulinum toxin products suggests the development of neutralizing antibodies against the core BonTa neurotoxin. In light of the patient's lack of response, it was determined to cease all botulinum toxin treatments. A management plan was established to reassess the patient annually with IncobotulinumtoxinA, based on the hypothesis that neutralizing antibody titres may decline over time, allowing for potential future therapeutic responses. Conclusion: The formation of neutralizing antibodies to the BonTacore neurotoxin has been demonstrate and proven by essays. A proposal to continuously developing BonTa formulations free of complexing proteins and other immunogenic excipients is necessary, and the shift towards these formulations such as IncobotulinumtoxinA as a first line cosmetic toxin, preventing such issues in future. Continued monitoring and research into the mechanisms of tolerance are warranted to optimize treatment strategies for patients experiencing similar issues.