Toxin vs toxin: How do you choose?

Botox still boasts the biggest name in neurotoxins, but competitors have added a new wrinkle for cosmetic surgeons and their patients: Is Botox the best? Or should they try Dysport or Xeomin instead?

Dr. GutowskiKarol A. Gutowski, M.D., FACS, a plastic surgeon based in Chicago, says there aren't many clinical reasons to choose one over the other. "While there are minor differences between them, these products seem to be much more similar than different," he says. "I'm not going to say they’re interchangeable, but they’re pretty close to it."

But this doesn't mean the three drugs are all the same, says Dr. Gutowski, who spoke in a conversation with Cosmetic Surgery Times and at a presentation during Plastic Surgery The Meeting 2016 in Los Angeles. Doses and costs differ, he says, as do the ideal patients for each medication. And other factors may play roles too.

According to Dr. Gutowski, there are issues to consider when prescribing a botulinum neuromodulator for cosmetic purposes.

Is Faster Onset Better?

In Dr. Gutowski's experience, Dysport has the fastest time to onset — one to three days. "It kicks in a few days earlier, but most people don’t come in and say 'I’ve got to look good this weekend,'" he says.

Does the Patient Have a Favorite Brand?

Dr. Gutowski says he educates his patients about the three options and doesn't stand in their way if they express a preference that is appropriate for them. 

"They may have been getting Botox for a long time; they may have an account that gets them a rebate; they may get points. If they like that, that’s fine," he says. "I have one patient who likes Dysport, and some like Botox because it's the brand everybody knows."

NEXT: Is the Patient Price-Sensitive?

Is the Patient Price-Sensitive?

"Some are willing to pay a little bit more for a brand they know, but others don't care as long as it will work," Dr. Gutowski says. "They'll say, 'Give me the one that's most cost-effective.'"

According to him, Xeomin is the least expensive of the three drugs. Dysport is in the middle, and Botox is as expensive or more expensive than Dysport.

He recommends keeping an eye on the usage of the drugs at your clinic. If volume is lower, it may not be financially wise to offer more than one or two of the three drugs because of the risk of waste, he says.   

Is One Brand More Appropriate for the Patient?

"There are some people who get excellent results with all three products," Dr. Gutowski says, but there may be exceptions.

Dysport, for example, is not appropriate for people with cow's milk allergies, and it may cause more injection pain. It also seems to have a wider diffusion area, he says, "but how much it matters clinically is a little harder to say."

NEXT: Does the Patient Need a Duration Boost?

Does the Patient Need a Duration Boost?

Dr. Gutowski says he hasn't noticed a difference in the duration of effects between Botox, Dysport and Xeomin. Research backs him up: A 2016 systematic review examined use of the drugs as treatments for wrinkles and found "there is insufficient evidence demonstrating an increased duration of benefit of any one medication relative to its competitors."

But Dr. Gutowski has seen the effect of neurotoxins wear off in less than three months in some patients. What to do? One option is to try to increase the duration of wrinkle relief through the use of zinc supplementation.

Dr. Gutowski points to a double-blind, placebo-controlled 2012 study that found the effects of the toxins lasted longer in 92% of subjects who took a zinc and phytase supplement; the average increase in duration was almost 30%.

The phytase product — which claims to provide "nutritional support to enhance the effectiveness of botulism toxin injections" — costs $40 per treatment. It is also known as Zytaze.

Disclosures: Dr. Gutowski has a speaker relationship with Suneva Medical.