Botox vs Xeomin for axillary hyperhidrosis

Incobotulinumtoxin A (Xeomin, Merz Aesthetics) is a “suitable” alternative to onabotulinumtoxin A (Botox, Allergan) for the treatment of axillary hyperhidrosis, according to a small evaluation presented in October at the American Society for Dermatologic Surgery (ASDS) Annual Meeting in Phoenix, Ariz.

While onabotulinumtoxin A is the only FDA-approved botulinum toxin for the indication, it can be an expensive option for large health systems like The U.S. Department of Veterans Affairs (VA). The VA negotiated better pricing for incobotulinumtoxin A and, therefore, designated incobotulinumtoxin A as the preferred botulinum toxin A treatment for veterans with a number of indications, including axillary hyperhidrosis, according to the poster’s description in the ASDS’s meeting program.

The negotiated price difference between the two drugs is substantial, according to the presented poster. VA pricing for onabotulinumtoxin A (100 u) is $428.64, versus incobotulinumtoxin A (100 u) at $285.87. That’s a per-unit savings of about 33%, according to the poster.

Researchers reported their experience in a retrospective review of 12 patients, including nine treated previously with onabotulinumtoxin A and later with incobotulinumtoxin A and three treated with incobotulinumtoxin A only, during a 12-month period. Providers informed the patients treated at the VA Palo Alto Health Care System that incobotulinumtoxin A was an off-label treatment for axillary hyperhidrosis.

Nearly 90% of the patients treated with both botulinum toxins reported comparable efficacy; 11% reported incobotulinumtoxin A’s effects didn’t last as long as those from onabotulinumtoxin A.

None of the patients reported adverse effects including muscle weakness or the drug’s spread to distant sites. Additionally, patients’ reports of pain with injection were about the same between the toxins.

The longest duration of effect for both toxins was nine months. Patients reported an on-average duration between five and six months for both toxins.

A special consideration in the veteran population is that some have been immunized for botulinum toxoid, which could result in treatment resistance. But in this report, none of the patients reported having the vaccination.

Presentation co-author Stephen Lewellis, M.D., Ph.D., a dermatology resident in his final year of training at Stanford University, tells The Aesthetic Channel that it’s his gut feeling onabotulinumtoxin A and incobotulinumtoxin A are interchangeable for treatment of axillary hyperhidrosis.

“We are still gathering data from our experience to make an evidence-based conclusion based on our practice. However, there is available data in the literature that provides reassurance. For example, there was a randomized controlled trial published in 2010 showing no detectable difference in efficacy or adverse effects with use of incobotulinumtoxin A compared to onabotulinumtoxin A for axillary hyperhidrosis (Dressler 2010),” Dr. Lewellis says.

Dosing is also the same.

“Given the 1:1 dosing equivalence that is generally accepted for incobotulinumtoxin A and onabotulinumtoxin A, I administer them both in the same manner,” he says.

Dr. Lewellis says that because of the small number of patients evaluated he’s hesitant to put too much weight on the finding that 11% indicated the duration of effect was longer with onabotulinumtoxin A.

Available evidence, including this poster, may be enough to suggest the move from using onabotulinumtoxin A to incobotulinumtoxin A is a good one for the health system and patients, according to the authors. 

Although larger, controlled studies are needed, this study suggests that incobotulinumtoxin A is a safe and effective alternative to onabotulinumtoxin A for the treatment of axillary hyperhidrosis, according to the poster.

“This supports the decision to transition to a more cost-effective botulinum toxin in this large single payer system,” the authors write.