Can using 2 different neurotoxins at 1 appt (e.g. Botox & Daxxify) increase or decrease the risk of resistance?

Question

I get medical Botox on my temporalis and masseter & also get Botox for cosmetic purposes on 11's, forehead lines, and crows feet. But I'm considering trying a different neurotoxin like Daxxify, Dysport, or Xeomin for the cosmetic part and sticking with Botox for the medical part. Hypothetically, would using 2 different neurotoxins simultaneously increase or decrease the likelihood of resistance? And can you explain your reasoning?

Kally Papantoniou, MD, FAAD · Answer

Using two different neurotoxins at one appointment (like Botox for medical areas and Daxxify, Dysport, or Xeomin for cosmetic ones) doesn’t clearly change your risk of resistance. Antibody formation is more related to total toxin exposure and the presence of accessory proteins in certain brands. Xeomin, which is free of complexing proteins, is sometimes chosen for patients worried about resistance. Overall, resistance is rare when treatments are appropriately dosed and spaced.

Ella Fedonenko, MD · Answer

Using 2 different botulinum toxin products simultaneously is probably not a good idea since doing that was not formally studied and it may cause unknown or increased side effects.To overcome resistance(if it develops) I would simply switch to a different botulinum toxin product.

Anna Chacon, MD, FAAD · Answer

The use of two different neurotoxins, such as Botox (onabotulinumtoxinA) and Daxxify (daxibotulinumtoxinA-lanm), at the same appointment is an interesting consideration, especially in the context of potential resistance.

Resistance to Neurotoxins:

Mechanism of Resistance: Resistance to botulinum toxin can occur when the immune system develops antibodies against the neurotoxin, potentially reducing its effectiveness over time. This is more likely when higher doses or more frequent treatments are used.

Different Formulations: Each neurotoxin formulation has unique properties and may vary in terms of protein load and formulation, which could influence the immune response. For instance, Botox and Daxxify have different accessory proteins and stabilization techniques.

Risk of Resistance: Using different neurotoxins theoretically might reduce the risk of resistance to one specific type, since the body is exposed to varied formulations. However, this is not fully established in clinical studies. The risk of resistance is generally low with appropriate dosing and frequency.

Clinical Considerations: There is limited direct evidence regarding the simultaneous use of different neurotoxins and its impact on resistance. Some practitioners may opt for alternating between different products to potentially mitigate resistance, though this strategy is more anecdotal than evidence-based.

Professional Guidance: It is crucial to discuss this approach with a healthcare provider experienced in neurotoxin treatments. They can provide personalized advice based on your medical history, treatment goals, and any previous responses to neurotoxin therapy.

Ultimately, the decision should be guided by clinical judgment, individual patient response, and ongoing consultation with a healthcare professional.

Tulsi Kotecha, MD · Answer

Hey there! This is Dr. Kotecha. I love this question because I get it often from patients who are curious about switching up their neurotoxins.
The short answer? Using two different neurotoxins (like Botox & Daxxify) in one session isn’t likely to increase or decrease your risk of developing resistance. But let me explain why.
Resistance to neurotoxins happens when your body builds neutralizing antibodies against the active ingredient (botulinum toxin type A). This is rare, but when it does happen, it’s usually due to high doses, frequent treatments, or exposure to complexing proteins found in some formulations.
I actually use Daxxify and Botox (or Xeomin) in the same treatment quite frequently based on my patients’ goals, budgets, and how long they want their results to last. Some patients want the longevity of Daxxify for their frown lines but stick with Botox for medical reasons like TMJ or migraines. Others prefer Xeomin because it’s a “naked” toxin (without extra proteins) and may have a lower risk of resistance in the long run.
That said, there’s no strong evidence that using multiple neurotoxins at the same time will impact resistance much. Since they all share the same active ingredient, your immune system isn’t likely to treat them too differently.
What really matters is how often you’re getting treated, the total dose over time, and whether your body is prone to forming antibodies. If you’ve been on Botox for years and are noticing it’s not lasting as long, that might be a sign to try another brand. Otherwise, using two in one session isn’t a major factor in resistance.

Camille Cash, MD · Answer

Resistance to neurotoxins is rare.  We do sometimes find that patients feel one neurotoxin provides more of the results that they are wanting.  If a patient has developed resistance they may find that they can use a different neurotoxin effectively as they are each formulated slightly differently.  Mixing two neurotoxins would not impact future potential resistance.

Leonard Grossman, MD · Answer

Mixing different neuromodulators such as Botox or  Xeomin  will not create resistance to any of the products. Resistance is a naturally occurring reaction.

Can using 2 different neurotoxins at 1 appt (e.g. Botox & Daxxify) increase or decrease the risk of resistance?

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