There are five FDA-approved botulinum toxin cosmetic injectables. Here’s how to choose the one that’s right for you.
When it comes to a scraped knee, you probably reach for a Band-Aid. Sneeze attack? Kleenex, please! Sometimes a brand is so good, so ubiquitous, that it ends up defining an industry. The same could be said for Botox.
Botox is, as you are probably well aware by now, one type of botulinum toxin injectable. A quick science lesson: Botulinum toxin is a neuromodulator, which is the fancy name for a class of chemicals that interrupt the signals between nerves and muscles causing muscles to relax and wrinkles to subside. “Injections of botulinum toxin temporarily inhibit the nerve cells that signal specific muscles to contract, therefore weakening facial movements that cause fine lines and wrinkles,” explains Corey L. Hartman, MD, a board-certified dermatologist in Alabama. The injections are most commonly used to relax glabellar muscles between the brows (often referred to as 11 lines) as well as lines on the forehead and crow’s-feet.
Now to get really technical: Botulinum toxin comes from a bacterium called Clostridium botulinum, explains Hardik Doshi, MD, a double board-certified plastic surgeon in Long Island, New York. The bacteria secretes eight different subtypes of botulinum toxin; type A is considered one of its strongest toxins and is the only commercially available form of botulinum toxin for cosmetic use.
That botulinum toxin type A is what we tend to call Botox because it has the longest track record — it was the first neuromodulator injectable ever — and still has the biggest market share. It works so well that more neuromodulators followed and now Botox isn’t the only option.There are currently five FDA-approved injectable neuromodulators: Botox (which was approved in 2002), Dysport (which came on the scene seven years later), Xeomin (approved in 2011), Jeuveau (2019), and the newest player in the market, Daxxify.
With the recent approval of Daxxify in September 2022, we decided to look into what really sets these injectables apart. They’re all designed to address the same types of dynamic wrinkles, which are caused by muscle movement and often pop up or become most pronounced when you express emotions. They all contain the same active ingredient, botulinum toxin type A. And they all work the same way, by blocking neurological signals to the muscles, reducing the appearance of wrinkles at the point of injection, says Ranella Hirsch, MD, a board-certified dermatologist in Boston.
This all raises a lot of questions like: How do you choose which kind of injection to get? How different are they really? Is it just marketing or are some better at relaxing certain wrinkles — say, crow’s-feet — versus others? See, lots of them!
In the interest of figuring out what you should know before going to your dermatologist or plastic surgeon, it’s good to know what to avoid: price shopping. It’s really not the best place to start. You may have read articles with comparisons, like one unit of Botox is equal to three units of Dysport, making Botox the more cost-effective option. These analogies are faulty by nature: They assume providers are using identical dilutions, which is rarely the case, Dr. Hirsch explains. Varying the concentration, she adds, can be totally fine. Some doctors prefer something more or less dilute, and even a single injector might vary concentrations for different areas of treatment depending on the patient’s anatomy. But because units are not standardized across the field, a less-than-reputable place could theoretically (and often does) offer lower prices using a markedly lower dilution and consumers would never know the difference.
So, no matter which neuromodulator you choose, first thing’s first: Vetting the doctor — and we do mean doctor, not med spa aesthetician — is crucial. It is the single most important thing a patient can do not only for their safety, but also to ensure the fairest deal and the best possible outcome. You want an injector that has a real mastery of the muscles of facial expression and in-depth knowledge of how the different products perform, says Dr. Hartman. “It never hurts to look at the injector to make sure they haven’t over-treated themselves,” he explains. “If the staff and doctor can express themselves in a natural-appearing way then you are likely in good hands.” And with all of the med spas and unqualified injectors out there, it bears repeating: Always make sure your provider is a board-certified dermatologist or plastic surgeon. You can check their credentials at certificationmatters.org.
Now that we know to avoid comparisons by price tags and injections at med spas, we can turn to the main distinctions between brands: Their formulation, how much each spreads (in other words, how large an area a single injection can cover), how quickly you can expect to see results, and how long each lasts. Below, we break down the five neuromodulators on the market and how they stack up.
Botox
Botox is the OG neuromodulator with the most extensive performance history and largest market share. It’s also the only neuromodulator approved for all three of the major treatment areas: between the brows, the forehead, and crow’s-feet.
Botox, or onabotulinumtoxinA (not a typo), was officially cleared for cosmetic use in 2002 to smooth vertical lines between the eyebrows (known as glabellar lines). Since then, it’s been approved to treat crow’s-feet (in 2013) and moderate-to-severe forehead lines (in 2017), though doctors had been regularly using it off-label on both areas for years. It’s worth noting that other neuromodulators are only approved for treating frown lines (though doctors use other brands’ neuromodulators off-label, too), Dr. Doshi says. Other off-label cosmetic uses for Botox include softening lip lines, chin wrinkles, and neck bands, as well as giving patients subtle brow lifts and lip flips (in which injecting botulinum toxin A into the upper lip “flips” it slightly upwards, giving the appearance of larger lips).
With fairly little downtime (usually a little redness around the injection site for 15 minutes to a day), results start to kick in as early as day three or four, though the full effects can take up to two weeks to appear and last anywhere from two to four months. To keep results going, touch-ups are recommended every three to four months. Cosmetic use aside, Botox can treat medical conditions including excessive sweating, chronic eyelid twitching, chronic migraines, urinary incontinence, neck spasms, and other types of muscle spasms.
Most first-timers opt for Botox over other neuromodulators, Dr. Hartman explains, though the choice is more about its name recognition and extensive track record than differing cosmetic benefits. He also says he’s a fan of using Botox, in particular when it comes to brow lifts in the lateral eyebrow. Its precision means there’s less risk of brow ptosis (which is when the brow drops lower than normal, to the point of potentially causing vision impairment).
Dysport
Dysport’s claim to fame is its spreadability making it ideal for larger areas like the forehead. It also sets in slightly faster than its competitors and anecdotal evidence suggests it may last longer too, making it a popular choice among seasoned neurotoxin users.
Dysport, also known as abobotulinumtoxinA, was FDA-approved in 2009 to temporarily improve the appearance of moderate-to-severe glabellar lines and for the treatment of cervical dystonia in adults (a painful condition in which neck muscles involuntarily contract causing the head to twist or turn to one side). Results typically show up in a few days and can take up to a week to fully set in, making it work slightly faster than Botox, according to Dr. Doft. As a result, she says her patients tend to like Dysport the best, a sentiment she shares. “I find that it works quickly and lasts an equally long time as its competitors, if not longer,” she says. Dr. Hartman echoes her findings, sharing that many of his patients and staff who have tried multiple neuromodulators report that Dysport kicks in fastest and lasts longest.
What really sets Dysport apart is its spreadability. As Dr. Doshi explains, the specific protein used in Dysport has a lower molecular weight than the protein used in Botox, allowing a Dysport injection to diffuse through tissues. (The proteins are mostly there to stabilize the toxin and improve absorption, Dr. Doft says.) Dysport’s faster diffusion rate translates to a thorough, even improvement in lines without a heavy feel, Dr. Hartman adds. That’s particularly helpful when treating large areas like the forehead since the spreadability allows for full results from fewer injections. “Dysport really shines when injected in the forehead where it spreads well and covers this large, flat muscle in a complete way that allows for some movement,” Hartman shares. On the flip side, that same spreadability is less favorable when targeting more precise muscles like those around the brow.
Another potential benefit is reduction in oil production in the skin, according to a 2021 study, published in Toxins, an international, peer-reviewed journal. While the study mentions that all neurotoxin injections have the potential to limit oiliness and shine, it suggests that Dysport seems to be best for this purpose.
“Dysport works very well for decreasing sweat and oil production and pore size,” explains Dr. Doft. “By using small aliquots of the toxin, you can reduce the production of both by affecting sebaceous glands. I have used it more to decrease sweat production in the axilla [armpit], hands, and feet.” Dr. Hartman reports reading the same about Botox and suggests that if there is, indeed, an impact on oil production, it would likely be a class effect seen in all five neurotoxins on the market. However, Dysport (like all other neurotoxin injections, for that matter) is not FDA-approved to treat oiliness, so additional research would likely be needed.
Jeuveau
One of the only two neuromodulators approved for aesthetics-only usage (the other is Daxxify), Jeuveau has only been on the market since 2019, meaning research and performance history is fairly limited.
The second most recent neurotoxin injectable on the market, Jeuveau, or PrabotulinumtoxinA, was approved to treat moderate to severe lines between the eyebrows. According to Dr. Doshi, Jeuveau is similar to Botox — a double-blind, placebo-controlled study from 2019 found that Jeuveau was as effective for treating forehead lines. Its main point of differentiation, Dr. Doshi says, is that it’s the first neurotoxin developed solely for aesthetic and cosmetic purposes (whereas its competitors also treat muscle spasms and other medical conditions).
There’s anecdotal evidence that Jeuveau has a quicker onset than other neuromodulators and in a clinical trial it appeared to last longer for about a third of participants (five months, rather than the standard three). But Dr. Hirsch says evidence that it lasts longer or kicks in faster is fairly limited and inconclusive.
Dr. Hartman makes a point of mentioning that Jeuveau may actually work better for men than its competitors. Interestingly enough, Evolus (the brand that makes Jeuveau) published a peer-reviewed, double-blind study in the Aesthetic Surgery Journal that showed with high consistency that men treated with Jeuveau had higher responder rates than those treated with Botox. While that lines up with Dr. Hartman’s sentiment, it’s important to keep in mind a few things: First of all, the findings here were reported by Evolus rather than an independent third party. Also, due to the small sample size (56 men, 25 received Jeuveau and 31 received Botox), results from the study did not reach statistical significance and any conclusive takeaways would need further research. Still, it’s interesting stuff.
Xeomin
Meet the naked neurotoxin, Xeomin. While that doesn’t really mean much for the average consumer, its formula uniquely doesn’t contain the same kinds of proteins as the others.
Considered more “natural” by some due to its lack of stabilizing proteins, Xeomin, or incobotulinumtoxinA, was approved for cosmetic use to treat frown lines between the brows in 2011. The suggestion that it’s purer or more natural because of a lack of these proteins, by the way, simply doesn’t hold. The biggest difference between Xeomin and most competitors is that it remains stable at room temperature and doesn’t need to be refrigerated prior to use, which makes no difference to the average patient.
While results can appear in three to four days, Xeomin may feature a slightly longer onset period than the rest, with maximum effects setting in around 30 days. Results tend to last about one to three months, says Dr. Hirsch, making it the shortest-acting option, which can actually be quite beneficial for first-time patients, who may feel hesitant about results that last four to six months.
The lack of additional proteins means, theoretically, that patients are less likely to develop antibodies to Xeomin compared to its competitors, says Dr. Doshi. Doctors Doshi, Hartman, and Doft are all quick to point out that it’s simply a theory, not fact. And while Dr. Hartman reports seeing many patients who lose the effects of Botox and do better with Xeomin, he says the findings are largely anecdotal. Dr. Doft agrees, saying that while she’s heard of some patients who report decreased sensitivity to Botox or Dysport after years of use, she hasn’t seen a significant amount of that in her practice.
Daxxify
The most recent addition to the neuromodulator line-up, Daxxify has been making major headlines as the new, longest-lasting option on the market. While it won’t be widely available until 2023 (Revance Therapeutics, its parent company, says most people won’t have access until the summer), it’s already slated to make a major splash in the world of injectables.
New kid on the block Daxxify, also known as daxibotulinumtoxinA, was approved to treat frown lines between the brows in September 2022. Its real selling point is that results seem to last longer than any other neuromodulator. In trials submitted to the FDA by Revance, compared with a placebo, about 80 percent of participants saw improvements in facial lines four months after treatment and about half of the participants saw sustained improvements after six months. Some even continued to report results after nine months — results that could translate to a single annual appointment (or two biannual appointments) for upkeep.
Needless to say, these extended results could be a major game changer, especially for seasoned neuromodulator users who might prefer coming in for just one or two appointments a year. Remember, most brands recommend getting touch-ups every three to four months, so the possibility of twice-a-year injectable appointments is seriously appealing, not to mention likely cheaper. Patients potentially could maintain the same results with half the number of injections.
Daxxify’s staying power is derived from its unique stabilizer. Instead of using a protein (like Botox, Jeuveau, and Dysport), Daxxify has a peptide attached to it, which Dr. Doft says is thought to stabilize the toxin for longer periods of time. According to Dr. Hartman, it’s theorized that the peptide then enhances absorption, resulting in a more stable attachment to the neurotransmitter after injection for prolonged results.
But that staying power can be a double-edged sword: Because results last so long, those unsatisfied with the treatment will need to wait longer for the effects to wear off than they would with other injectables. Dr. Doft agrees, “This may not be the choice toxin for a first-time user who wants to try a neurotoxin, but may be better for someone who knows that they like the effects of a neurotoxin and feels comfortable with their physician as an injector.”