AESTHETICS


aS PharMacIStS BEgIn to BE traInEd In ProVIdIng aESthEtIc trEatMEntS, ProfESSor donald caIrnS, PharMacISt and hEad of thE School of PharMacY and lIfE ScIEncES at roBErt gordon UnIVErSItY, aBErdEEn, tEllS SP WhY PharMacIStS arE WEll PlacEd to do So.


Should pharmacists become involved in the cosmetic use of Botulinum Toxin? Botulinum toxin (‘Botox’) is a widely used cosmetic treatment, and concerns have been raised about its widespread availability and ease of supply by non-qualified practitioners. In this article I would therefore like to answer the question, should pharmacists be involved in supply and administration of Botox?


Background Botulinum toxin is a neurotoxic protein (relative Molecular Mass = 149,000 g mol-1) produced by the bacterium clostridium botulinum and is the major cause of the disease called ‘botulism.’


there are actually eight different variants of the toxin (known as Btx-a to h) of which Btx-a is the most widely used (for a review see ¹ and refs therein). care must be taken when using or handling Botulinum toxin as the substance is regularly named in the literature as ‘the most toxic substance known to science,’ although this accolade is also given to nerve agents and radioactive elements, such as plutonium. the most toxic variant is Btx-h with documented fatalities occurring following injection of as little as 2 ng of the substance (2 x 10 -9 of a gram)².


the main medical use for the toxin is the treatment of spasticity and excessive muscle tone associated with cerebral palsy (cP) and post-stroke injury although it has been investigated for the treatment of chronic migraine³, intractable pain4 and excessive sweating (hyperhidrosis)5


, .


treatment is usually by I/M injection of the toxin into the affected muscle group and is often combined with intense physiotherapy and exercise coupled with orthotic interventions, such as splinting and casting¹.


Mode of action the mode of action of the toxin is via inhibition of nerves using


acetylcholine as a neurotransmitter. the toxin binds specifically to the membrane of the nerve cell and is absorbed by endocytosis. once inside the cell, Botulinum toxin acts to cleave key proteins essential for the release of neurotransmitter. this completely inhibits nerve signalling and the muscles innervated by the nerve become flaccid and paralysed6


.


this effect is temporary and reversible, with normal neural function returning within 12–16 weeks¹. Patients with cP often require repeated administration of the injection every few months to maintain the reduction of excessive tone7


.


Botulinum toxicity Injection of Botulinum toxin is associated with toxicity and side- effects. these are usually as a result of inappropriate injection of the toxin into muscle groups adjacent to the injection site (although there have been cases of toxicity to the practitioner, due to needlestick injuries)8


.


the symptoms of toxicity include paralysis of critical muscle groups and may involve arrhythmia, and in some cases, seizures, respiratory arrest, and death9


months and repeated injections are required to maintain the ‘youthful’ appearance10, 11


. Excessive use of


Botulinum toxin injection may lead to the face becoming ‘mask-like’ with the patient unable to move their eyebrows or register surprise11


.


Treatment by pharmacists as discussed above, Botulinum toxin is a spectacularly toxic substance and great care should be taken when handling or administering the material. currently, administration for medical purposes is undertaken by physicians specialising in orthopedics or paediatrics, plastic surgeons, or by suitably trained nurse practitioners.


Pharmacists are the acknowledged experts in drugs and medicines and have been trained throughout their four years at university and their one year pre-registration experience to handle potent and toxic materials safely. It is therefore appropriate for pharmacists to use this training and experience to administer Botulinum toxin to patients for cosmetic procedures.


. Specific side effects associated


with cosmetic use may include muscle weakness, dysphagia (difficulty swallowing food), allergic reactions, and flu-like syndromes9


.


a further clinical complication is that commercial preparations from different manufacturers may contain variants of the toxin which have been purified or formulated differently, meaning they are unlikely to exhibit equivalent bioavailability. required dosage should be calculated independently for each preparation, based on previous response and clinical experience7


.


Cosmetic use of Botulinum toxin In addition to its established medical use for the relief of excessive muscle tone, Botulinum toxin is increasingly being used for cosmetic applications. Injection of the toxin into facial muscles (particularly the upper third of the face) results in paralysis of these muscles and gives the appearance of fewer wrinkles around the eyes and forehead.


as with licensed medical use, the treatment wears off within a few


References 1.Molenaers, g; Van campenhout, a; fagard, k; de cat, Jos and desloovere, k. the use of botulinum toxin a in children with cerebral palsy, with a focus on the lower limb. J. child. orthop. 2010, Jun; 4(3): 183–195. 2. Weller c (15 october 2013). "new Botulinum toxin deemed deadliest Substance Ever: Sniffing 13-Billionths of a gram can kill". Medical daily. 3. Walsh S (october 15, 2010). "fda approves Botox to treat chronic migraine". fda Press releases. retrieved october 15, 2010. 4 Binder WJ, Brin Mf, Blitzer a, Schoenrock ld, Pogoda JM (december 2000). "Botulinum toxin type a (Botox) for treatment of migraine headaches: an open-label study". otolaryngology—head and neck Surgery. 123 (6): 669–76. doi:10.1067/mhn.2000.110960. PMId 11112955. 5. Walker tJ, dayan Sh (february 2014). "comparison and overview of currently available neurotoxins". the Journal of clinical and aesthetic dermatology. 7 (2): 31–39. PMc 3935649%. PMId 24587850. 6. Montecucco c, Molgó J (June 2005). "Botulinal neurotoxins: revival of an old killer". current opinion in Pharmacology. 5 (3): 274–79. doi:10.1016/j.coph.2004.12.006. PMId 15907915. 7. felber ES (october 2006). "Botulinum toxin in primary care medicine". the Journal of the american osteopathic association. 106 (10): 609–14. PMId 17122031. 8. Wicker, S; ludwig, a; gottschalk, r; rabenau, hf (2008). "needlestick injuries among health care workers: occupational hazard or avoidable hazard?". Wiener klinische Wochenschrift. 120: 486–92. doi:10.1007/s00508-008-1011-8. PMId 18820853. 9. coté tr, Mohan ak, Polder Ja, Walton Mk, Braun MM (September 2005). "Botulinum toxin type a injections: adverse events reported to the US food and drug administration in therapeutic and cosmetic cases". Journal of the american academy of dermatology. 53 (3): 407–15. 10. carruthers Jd, carruthers Ja (January 1992). "treatment of glabellar frown lines with c. botulinum-a exotoxin". the Journal of dermatologic Surgery and oncology. 18 (1): 17– 21. doi:10.1111/j.1524-4725.1992.tb03295.x. PMId 11 keen M, kopelman JE, aviv JE, Binder W, Brin M, Blitzer a (april 1994). "Botulinum toxin a: a novel method to remove periorbital wrinkles". facial Plastic Surgery. thieme Medical Publishers. 10 (2): 141–46. doi:10.1055/s-2008-1064563. PMId 7995530.


Botox: the positive medical effects


Yvonne and Stephen


did you know that, in addition to its ‘cosmetic’ qualities, Botox has also been proven to provide positive medical effects in the treatment of migraines, excessive sweating, overactive bladder and depression?


Stephen Mccoy, who was critically injured in the kegworth air disaster in 1989, and who is now paralysed down one side of his body, receives Botox injections in his left hand every four or five months. his sister, Yvonne, who cares for him, says that the benefits that Stephen gains from the injections far outweigh any down sides.


‘Botox was first suggested to us about three years ago by dr Mcdonald from Musgrave Park hospital,’ Yvonne tells SP. ‘Since Stephen is paralysed down his left side, it is up to me to keep his hand and nails clean to avoid any infection. this has on occasion proved very difficult as his hand is in a clenched position, with his nails often ‘dug’ into his hand.


‘Stephen now receives Botox injections into this hand and this ensures that his hand remains relaxed and ‘loose’, enabling me to cut his nails and keep his hand nice and fresh. the injection itself is painful – even though Stephen has no real feeling in the hand – but there’s no doubt that the benefits that the Botox brings to him – and me – far outweigh the pain or any down side. for a few days after the injection he has to wear a splint, but without it, I wouldn’t be able to ensure that I could keep his hand infection free.’


PharMacY In focUS - 53


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