Resistance to BoNT: Who lies? The muscle, the procedure, or the products?
Objectives: To encourage increased awareness around the potential issue of immunoresistance in aesthetic patients and strategies to minimise the risk.
Introduction: The Asia Pacific (APAC) region has witnessed evolving patterns in the usage of botulinum neurotoxin A (BoNT-A), with implications for immunoresistance in both therapeutic and aesthetic contexts. As off label indications increase, so do the frequencies and dosages of BoNT-A treatments, with growing numbers of patients seeking both preventative and high-dose aesthetic treatments. These trends contribute to a rise in secondary non-responsiveness due to immunogenicity, a condition where patients develop antibodies that reduce BoNT-A efficacy over time.
Materials / method: A cohort of 363 patients receiving high-dose off label aesthetic treatments were surveyed exploring their experience of symptoms related to possible immunogenicity and their injecting history.
Results: The results revealed that 92% of patients exhibited at least one symptom of declining efficiency and 49% exhibited three symptoms. These results contradict that published in the literature suggesting a 0.2% to 0.4% incidence of immune resistance in aesthetic patients. These results are discussed with insights from both patient and physician perspectives. Higher dose treatments and shorter treatment intervals are not yet routine outside the Asia Pacific region, but pre-dispose patients to a higher risk of developing BoNT-A immunoresistance.
Conclusion: Factors contributing to increased immunogenicity include higher cumulative doses, shorter intervals between treatments, and the use of non-approved indications that require elevated dosages. Ethical and clinical challenges arise as aesthetic BoNT-A treatments become more frequent and diverse, raising questions about long-term treatment planning and patient awareness.
Addressing these developments involves collaboration with clinicians, patients and regulators, underscoring the importance of educating patients and practitioners to mitigate immunoresistance risks.
