September 21, 2019

All About Neuromodulators

Neuromodulators, of which Botox is perhaps the best well known, are valued for their ability to reduce the appearance of fine lines and wrinkles. There are multiple medical indications some of which are neck spasms (cervical dystonia), excessive sweating (hyperhidrosis) or an overactive bladder.

All neuromodulators use a toxin called botulinumtoxin A with variable protein carriers for each formulation; abobotulinumtoxinA (Dysport), incobotulinumtoxinA (Xeomin) and most recently prabotulinumtoxinA (Jeuveau) to temporarily prevent muscle movement.  This toxin is produced by the microbe that causes botulism, a type of food poisoning but not to fear as the dosing that causes the life-threatening form of food poisoning called botulism and the amounts used to soften the years from your face are vastly different and therefore offer a favorable safety profile.

When injected, the botulinumtoxin A interrupts nerve signaling to your muscles and prevents the muscle from contracting.  This impairs (temporarily) muscle movement and leads to improvement in the appearance of fine lines and wrinkles.

Botox acts by binding to the receptor sites blocking the release of acetylcholine prevent the necessary nerve signaling to cause muscle contraction.

Despite all the positive applications of neuromodulators it is important to remember that it is a drug and it requires an injection.  According to the American Society of Plastic Surgeons, side effects include “bruising and pain at injection site, flu-like symptoms, headache, nausea, temporary facial weakness or drooping.” If the toxin spreads to other parts of the body, it can also cause “breathing problems, trouble swallowing, muscle weakness and slurred speech.”  However when administered by a trained professional after a thorough medical history and exam have been completed, the real risk is rather small.

In fact, only 36 cases of adverse effects associated with cosmetic use were reported to the U. S. Food and Drug Administration (FDA) between 1989 and 2003 1. Thirteen of these cases may have had more to do with an underlying condition than with the drug itself. Taken this fact with the reality that esthetic use of Botox uses even smaller doses one can assume that the risks are further lessened.  In general use of Botox, and its alternatives, is considered safe overall.

Minor side effects when using neuromodulators are possible. These include:

  • pain, swelling, or bruising at the injection site
  • headache
  • fever
  • chills

Some side effects are tied to the area of injection. For example, if you receive injections in the eye area, you may experience:

  • drooping eyelids
  • uneven eyebrows
  • dry eyes
  • excessive tearing

Most side effects are usually temporary and should fade within a few days.

In rare cases, you may develop botulism-like symptoms. Seek immediate medical attention if you begin experiencing:

  • difficulty speaking
  • difficulty swallowing
  • difficulty breathing
  • vision problems
  • loss of bladder control
  • general weakness

During your consultation:

  • You must tell your doctor if you have had an allergic reaction to any botulinum toxin products such as Botox (onabotulinumtoxin A) Dysport®(abobotulinumtoxinA), prabotulinumtoxinA (Jeuveau) or Xeomin® (incobotulinumtoxinA)
  • have a skin infection at the planned injection site.
  • Are pregnant or breast feeding.
  • Suffer from muscle or nerve conditions, such as ALS or Lou Gehrig’s disease, myasthenia gravis, or Lambert-Eaton syndrome, as you may be at increased risk of serious side effects including difficulty swallowing and difficulty breathing from typical doses of BOTOX®
  • Lastly be sure to tell your doctor what medications you are taking specifically any blood thinning medications such as warfarin (Coumadin), apixaban (Eliquis), rivaroxaban (Xarelto) or dabigatran (Pradaxa).


The injections usually begin working one to three days after treatment. Depending on the problem being treated, the effect may last three months or longer. To maintain the effect, you’ll need regular follow-up injections.


  1. Cote, Mohan et al. Botulinum toxin type A injections: adverse events reported to the US Food and Drug Administration in therapeutic and cosmetic cases. J Am Acad Dermatol.2005 Sep;53(3):407-15.
  2. Brin MF, Boodhoo, TI et al. Safety and tolerability of onabotulinumtoxinA in the treatment of facial lines: a meta-analysis of individual patient data from global clinical registration studies in 1678 participants. J Am Acad Dermatol.2009 Dec;61(6):961-70.e1-11. doi: 10.1016/j.jaad.2009.06.040. Epub 2009 Sep 9.
  3. Brin MF. Basic and clinical aspects of BOTOX. 2009 Oct;54(5):676-82. doi: 10.1016/j.toxicon.2009.03.021. Epub 2009 Mar 31.

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