Botox: Quick Fix, Serious Medicine

▪ 2003

      On April 15, 2002, the U.S. Food and Drug Administration (FDA) approved injections of botulinum toxin type A (trademarked Botox) for the treatment of facial wrinkles. The manufacturer, Allergan Inc., wasted no time in launching a $50 million advertising blitz to promote its already overwhelmingly popular product. In fact, doctors had been using the drug “off-label” to relieve patients of their wrinkles long before it was officially sanctioned for that purpose.

      The FDA approved Botox for just one type of wrinkle—frown lines. These vertical creases between the eyebrows result from lifelong use of particular facial muscles. When tiny amounts of a highly dilute, purified solution of botulinum toxin are injected into the muscles, they become temporarily paralyzed and can no longer cause the brow to furrow. As a result, the unwanted facial lines begin to soften and fade. The desired effect becomes apparent 3–10 days after the injections and lasts three to five months.

      Botox injections work best for frown lines but are also used for crow's-feet (laugh lines around the eyes), horizontal forehead lines, and neck creases. Ironically, the “wrinkle wonder drug,” as it has been called, is derived from one of the most poisonous substances known, the bacterial toxin responsible for botulism food poisoning. During the year its popularity was evidenced by the proliferation of Botox parties—group Botox treatments in casual social settings rather than a controlled medical environment. Professional medical societies in the U.S. and the U.K. considered such venues inappropriate and risky because individuals may not have been properly screened as suitable candidates for Botox or fully informed of potential side effects—e.g., headache, droopy eyelids, and redness. Furthermore, if alcohol is consumed, as it often is at Botox parties, the likelihood of bruising is increased.

      Botox is much more than a quick fix for wrinkles. In the 1970s doctors found that injections of botulinum toxin into overactive eye muscles alleviated strabismus (cross-eye) and blepharospasm (involuntary blinking). It was for these two conditions that the FDA originally approved Botox in 1989. In the early 1980s a Canadian couple—Jean Carruthers, an ophthalmologist, and her husband, Alastair Carruthers, a dermatologist—noticed the wrinkle-alleviating side effect of Botox and went on to pioneer its cosmetic use. Serendipity played a part again when an American physician who used Botox to treat wrinkles heard from several of his patients that they were having fewer headaches. Since then, more than a dozen studies have shown promising results for treating both chronic tension and migraine headaches with the drug.

      In December 2000 the FDA approved the related botulinum toxin type B (Myobloc) as well as Botox for treating cervical dystonia, which causes muscle contractions in the neck and shoulders and an abnormal head position. With these two products available, medical researchers were investigating them as promising treatments for a variety of other afflictions, including urinary incontinence, anal fissures, excessive perspiration, pain following hemorrhoid surgery, and physical disabilities caused by stroke and cerebral palsy.

Ellen Bernstein

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