Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine: five case reports

Abstract

Botulinum neurotoxin injections are a valuable treatment modality for many therapeutic indications as well as in the aesthetic field for facial rejuvenation. As successful treatment requires repeated injections over a long period of time, secondary resistance to botulinum toxin preparations after repeated injections is an ongoing concern. We report five case studies in which neutralizing antibodies to botulinum toxin type A developed after injection for aesthetic use and resulted in secondary treatment failure. These results add to the growing number of reports in the literature for secondary treatment failure associated with high titers of neutralizing antibodies in the aesthetic field. Clinicians should be aware of this risk and implement injection protocols that minimize resistance development.

Safety and Patient Satisfaction of AbobotulinumtoxinA for Aesthetic Use: A Systematic Review

“…49 The patients in this report all had a declining clinical response to BoNT-A over several injection sessions. They developed secondary treatment failure and tested positive for neutralizing antibodies using the mouse phrenic nerve hemidiaphragm assay, suggesting that the cause of the therapy failure was neutralizing antibodies to BoNT-A.…”

Repetitive injections of botulinum toxin A continuously increase the duration of efficacy in primary axillary hyperhidrosis: A retrospective analysis in 101 patients

“…As successful treatment requires repeated injections over a long period of time, secondary resistance to botulinum toxin resulting in decreased or even absent effectiveness is an ongoing concern. The formation of neutralizing antibodies against botulinum toxin A with secondary non‐response varies from 0.3–6 % . However, this phenomenon has been described in up to 10 % of patients treated with botulinum toxin A for dystonia and blepharospasm over a 10‐year period .…”

“…There was thus no evidence for any clinically relevant formation of neutralizing antibodies, albeit no respective laboratory analysis was performed. In general, the prevalence of patients developing neutralizing antibodies after long‐term botulinum toxin treatment depends on the respective indication (aesthetic or medical) and the doses given (the higher the dose, the higher the risk) . Although, the actual factors contributing to the formation of neutralizing antibodies have not been well characterized, protein load per effective dose and frequency of exposure have been suggested.…”

Global Aesthetics Consensus: Hyaluronic Acid Fillers and Botulinum Toxin Type A—Recommendations for Combined Treatment and Optimizing Outcomes in Diverse Patient Populations

“…Although a number of case reports describe secondary treatment failure in the presence of neutralizing antibodies, there is no high-level evidence to implicate antibodies as the actual cause. 50 Table 2 summarizes challenges in interpreting current data. 51–56 Ongoing monitoring of the increasing number of patients who receive repeated treatments will allow conclusions that are evidence-based, rather than circumstantial.…”