Prediction of Immunogenicity in Botulinum Toxin Type A Treatments for Glabellar Lines

The most commonly used brands are Botox, Xeomin and Dysport.

Botulinum toxin type A (BoNT-A), derived from the bacterium Clostridium botulinum and used in the commonly known brands “Botox, Dysport and Xeomin”, has become one of the most widely used tools in both aesthetic medicine and specialized medical treatments. From its use in reducing expression lines such as glabellar lines (the wrinkles between the eyebrows) to the management of chronic diseases such as cervical dystonia and migraines, BoNT-A offers proven results and wide acceptance. However, one important aspect that is not always discussed in sufficient detail is its immunogenic potential. What does this mean? That with repeated applications, the immune system can generate neutralizing antibodies (NAbs) that reduce or even nullify the effect of the toxin over time. Why does immunogenicity occur?

When the body detects foreign proteins, such as those present in BoNT-A, it can initiate an immune response. If the patient receives high doses or frequent treatments, the risk of producing these antibodies is greater. Over time, this can translate into reduced treatment effectiveness, the need to increase the dose, or change the product.

What factors most influence the formation of antibodies?

A recent study analyzed 14 clinical trials with more than 8,000 participants who received BoNT-A treatments specifically for glabellar lines. Using advanced machine learning models such as logistic regression and random forests, researchers identified the main risk factors:

• Dose administered: Higher doses increase the likelihood of developing antibodies.

• Treatment frequency: Very frequent applications increase the risk.

• Type of BoNT-A used: Not all products have the same immunogenic profile.
  

Which botulinum toxins present the least immunological risk?

The results showed significant differences between commercial products:

• IncobotulinumtoxinA was the lowest probability of generating neutralizing antibodies.

• AbobotulinumtoxinA showed the highest incidence of immunogenicity.

These differences have important clinical relevance, especially in patients requiring recurrent applications.

What implications does this have on aesthetic practice?

While antibody formation is uncommon with occasional cosmetic treatments, the likelihood may increase in those who receive BoNT-A on a sustained basis (e.g., every few months for years). Therefore, it is recommended:

• Personalize the treatment plan based on needs and frequency of administration.

• Use effective but not excessive doses.

• Consider the type of botulinum toxin based on its immunogenic profile.

• Inform patients about the possibility, although rare, of loss of efficacy over time.
  

Conclusions

Botulinum toxin type A remains a safe and effective option for treating glabellar lines and other aesthetic indications. However, understanding its immunogenicity allows physicians to optimize strategies and minimize risks. This study highlights the importance of carefully selecting the product and planning each treatment individually.

If you would like to learn more about how to prevent antibody formation and customize your botulinum toxin treatment, please do not hesitate to contact me. I´m here to guide you professionally and ethically every step of the way.

This article is based on information published in April 2025 by Rahman et al. in Plastic and Reconstructive Surgery.