Botox itself doesn't cause breakouts. Some causes of breakouts after any needle is injected in the skin are:1. Skin not properly cleaned prior to the injections2. Personal history of eczema through which a needle passed causing a skin infection3. Introduction of makeup into the dermis from a needle injected through insufficiently cleaned skin4. Cross contamination in the bottle of Botox if new sterile needles are not used to draw up the Botox 5. Botox kept too long in between uses6. Botox diluted (it always has to be diluted with a sterile liquid saline as it comes in a powder) with a non sterile saline or liquid other than saline to which the skin is reacting.7. Cold soresOnce in a while, in the practice of medicine, everything may be done perfectly correctly but the result is extremely unusual because of the patient's individual unusual medical condition, immune system abnormalities, metabolic condition and reasons that are not understood. An unusual breakout shown in these photographs need to be brought to the attention of the injector immediately. If it was not a board-certified dermatologist or plastic surgeon I suggest you see such.The information provided in Dr. Shelton's answer is for educational purposes only and is not intended to constitute medical advice. The information provided should not be relied upon as a substitute for consultations with a qualified health professional who may be familiar with your individual medical needs. If you are experiencing a medical emergency proceed to your nearest emergency room.