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With increased experience, clinicians are finding other uses for Botox (Allergan). Apart from more popular applications such as treatment for excessive sweating or hyperhidrosis or to eliminate frown lines between eyebrows, Botox is being injected in the lower parts of the face to improve wrinkles and to optimize wound healing.
"More and more medical specialties are using it for a variety of applications," says Thomas Rohrer, M.D., an associate clinical professor of dermatology at Boston University and a dermatologic surgeon at Skincare Physicians of Chestnut Hill in Chestnut Hill, Mass. "Once we know what a molecule can do, we start hypothesizing about what else it can do."
Dr. Rohrer describes Botox as the most popular cosmetic procedure currently being used in the U.S. There were an estimated 2.5 million injections of Botox in 2004. One of the newest approaches is to use Botox in conjunction with a facial filler or laser, Dr. Rohrer notes.
"When people start using different technologies and have more experience with the technologies, they begin experimenting," Dr. Rohrer explains. "By using products in combination, those products act synergistically. It gives you better results than if either of them is used alone."
A study published in Dermatologic Surgery in March of 2004 compared treatment of the lateral periocular region (crow's feet) with broadband light alone to broadband light in combination with Botox A.
The investigators found that combination treatment yielded an improved response at treatment, both at rest and smiling, as well as an improved response to lentigines, telangiectasia, pore size, and facial skin texture compared to patients who received monotherapy.
A study led by Drs. Jean and Alastair Carruthers, published in Dermatologic Surgery in 2003, found that Botox A in combination with non-animal sourced hyaluronic acid - compared with hyaluronic acid alone - demonstrated combination treatment producing a better response at rest and on maximum frown.
The median time for reinjection furrow status occurred at 18 weeks in the arm where hyaluronic acid was administered alone, compared with 32 weeks for the combination therapy.
In addition to Botox being used in conjunction with other therapies, there is a trend to greater dilution of the product, Dr. Rohrer says.
The lower face and beyond
One trend that Dr. Rohrer has noticed is growing use of Botox in the lower half of the face.
"We initially used Botox in the upper half of the face, such as the glabella, forehead, and around the eyes," Dr. Rohrer tells Dermatology Times. "We are using more and more around the mouth and on the neck to some extent."
Another emerging area is to use Botox as therapy to manage pain.
"The molecule will have to be altered slightly to primarily target pain," Dr. Rohrer says. "You have to change the binding affinity and have it transition from binding to muscle to preferentially bind to pain fibers and sensory nerves."
He notes that patients who have had injections of Botox to eliminate facial wrinkles in the upper part of the face, like the glabella, indicate that they experience fewer headaches as a by-product of the treatment.
"Patients often mention that their headaches have gone away since Botox treatment and ask if there is a connection," Dr. Rohrer says.
Indeed, studies presented in 2005 at the annual meeting of the American Headache Society, comparing Botox and placebo, indicated reductions in the frequency of headache episodes and decreases in medication use to relieve headaches. The treatment was also well tolerated among subjects.
Botox and wound healing
Botox can be of benefit in the surgical setting to improve wound healing, according to Dr. Rohrer.