Botulinum toxin
Botulinum toxin, botulinum neurotoxin, or botox is a neurotoxic protein produced by the bacterium Clostridium botulinum and related species, and it is considered the deadliest known natural substance ever recorded in the chemical literature. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neuromuscular junction, thus causing flaccid paralysis. The toxin causes the disease botulism. The toxin is also used commercially for medical and cosmetic purposes. Botulinum toxin is an acetylcholine release inhibitor and a neuromuscular blocking agent. Botulinum was developed as a biological agent by the Soviet, United States, and Iraqi biological weapons programs.
The seven main types of botulinum toxin are named types A to G. New types are occasionally found. Types A and B are capable of causing disease in humans, and are also used commercially and medically. Types C–G are less common; types E and F can cause disease in humans, while the other types cause disease in other animals.
In 2025 the structure of the complete 14 subunit botulinum neurotoxin complex was solved.
Intoxication can occur naturally as a result of either wound or intestinal infection or by ingesting formed toxin in food. The estimated human median lethal dose of type A toxin is 1.3–2.1ng/kg intravenously or intramuscularly, 10–13ng/kg when inhaled, or 1μg/kg when taken by mouth.
Botulinum toxin is also notable for the paradoxical relationship between its extreme toxicity and its controlled therapeutic use. When administered in highly diluted, precisely measured doses, it can selectively inhibit muscle contraction, making it valuable in the treatment of conditions such as muscle spasticity, chronic migraines, and certain neurological disorders. This dual nature underscores the importance of dosage and delivery route in toxicology, as a substance that is lethal at nanogram quantities can be safely and effectively employed in medicine under strict regulation and clinical oversight.
Medical uses
Botulinum toxin is used to treat a number of therapeutic indications, many of which are not part of the approved drug label.Muscle spasticity
Botulinum toxin is used to treat a number of disorders characterized by overactive muscle movement, including cerebral palsy, post-stroke spasticity, post-spinal cord injury spasticity, spasms of the head and neck, eyelid, vagina, limbs, jaw, and vocal cords. Similarly, botulinum toxin is used to relax the clenching of muscles, including those of the esophagus, jaw, lower urinary tract and bladder, or clenching of the anus which can exacerbate anal fissure. Botulinum toxin appears to be effective for refractory overactive bladder.Other muscle disorders
, otherwise known as improper eye alignment, is caused by imbalances in the actions of muscles that rotate the eyes. This condition can sometimes be relieved by weakening a muscle that pulls too strongly, or pulls against one that has been weakened by disease or trauma. Muscles weakened by toxin injection recover from paralysis after several months, so injection might seem to need to be repeated, but muscles adapt to the lengths at which they are chronically held, so that if a paralyzed muscle is stretched by its antagonist, it grows longer, while the antagonist shortens, yielding a permanent effect.In January 2014, botulinum toxin was approved by UK's Medicines and Healthcare products Regulatory Agency for treatment of restricted ankle motion due to lower-limb spasticity associated with stroke in adults.
In July 2016, the US Food and Drug Administration approved abobotulinumtoxinA for injection for the treatment of lower-limb spasticity in pediatric patients two years of age and older. AbobotulinumtoxinA is the first and only FDA-approved botulinum toxin for the treatment of pediatric lower limb spasticity. In the US, the FDA approves the text of the labels of prescription medicines and for which medical conditions the drug manufacturer may sell the drug. However, prescribers may freely prescribe them for any condition they wish, also known as off-label use. Botulinum toxins have been used off-label for several pediatric conditions, including infantile esotropia.
Excessive sweating
Botulinum toxin injections are a modern clinical trend to treat hyperhidrosis, of which palmar hyperhidrosis is a frequent symptom. For example, AbobotulinumtoxinA has been approved for the treatment of axillary hyperhidrosis, which cannot be managed by topical agents.Migraine
In 2010, the FDA approved intramuscular botulinum toxin injections for prophylactic treatment of chronic migraine headache. However, the use of botulinum toxin injections for episodic migraine has not been approved by the FDA.Cosmetic uses
In cosmetic applications, botulinum toxin is considered relatively safe and effective for reduction of facial wrinkles, especially in the uppermost third of the face. Commercial forms are marketed under the brand names Botox Cosmetic/Vistabel from Allergan, Dysport/Azzalure from Galderma and Ipsen, Xeomin/Bocouture from Merz, Jeuveau/Nuceiva from Evolus, manufactured by Daewoong in South Korea. The effects of botulinum toxin injections for glabellar lines typically last two to four months and in some cases, product-dependent, with some patients experiencing a longer duration of effect of up to six months or longer. Injection of botulinum toxin into the muscles under facial wrinkles causes relaxation of those muscles, resulting in the smoothing of the overlying skin. Smoothing of wrinkles is usually visible three to five days after injection, with maximum effect typically a week following injection. Muscles can be treated repeatedly to maintain the smoothed appearance.DaxibotulinumtoxinA was approved for medical use in the United States in September 2022. It is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines. DaxibotulinumtoxinA is an acetylcholine release inhibitor and neuromuscular blocking agent. The FDA approved daxibotulinumtoxinA based on evidence from two clinical trials, of 609 adults with moderate to severe glabellar lines. The trials were conducted at 30 sites in the United States and Canada. Both trials enrolled participants 18 to 75 years old with moderate to severe glabellar lines. Participants received a single intramuscular injection of daxibotulinumtoxinA or placebo at five sites within the muscles between the eyebrows. The most common side effects of daxibotulinumtoxinA are headache, drooping eyelids, and weakness of facial muscles.
LetibotulinumtoxinA was approved for medical use in the United States in February 2024. It is indicated to temporarily improve the appearance of moderate-to-severe glabellar lines. The FDA approved letibotulinumtoxinA based on evidence from three clinical trials of 1,271 participants with moderate to severe wrinkles between the eyebrows for efficacy and safety assessment. These trials were conducted at 31 sites in the United States and the European Union. All three trials enrolled participants 18 to 75 years old with moderate to severe glabellar lines. Participants received a single intramuscular injection of letibotulinumtoxinA or placebo at five sites within the muscles between the eyebrows. The most common side effects of letibotulinumtoxinA are headache, drooping of eyelid and brow, and twitching of eyelid.
Others
Botulinum toxin is also used to treat disorders of hyperactive nerves including excessive sweating, neuropathic pain, and some allergy symptoms. In addition to these uses, botulinum toxin is being evaluated for use in treating chronic pain. Studies show that botulinum toxin may be injected into arthritic shoulder joints to reduce chronic pain and improve range of motion. The use of botulinum toxin A in children with cerebral palsy is safe in the upper and lower limb muscles.Side effects
While botulinum toxin is generally considered safe in a clinical setting, serious side effects from its use can occur. Most commonly, botulinum toxin can be injected into the wrong muscle group or with time spread from the injection site, causing temporary paralysis of unintended muscles. In at least three cases temporary diplopia was reported due to subcutenious injections for cosmetic purposes.Side effects from cosmetic use generally result from unintended paralysis of facial muscles. These include partial facial paralysis, muscle weakness, and trouble swallowing. Side effects are not limited to direct paralysis, however, and can also include headaches, flu-like symptoms, and allergic reactions. Just as cosmetic treatments only last a number of months, paralysis side effects can have the same durations. At least in some cases, these effects are reported to dissipate in the weeks after treatment. Bruising at the site of injection is not a side effect of the toxin, but rather of the mode of administration, and is reported as preventable if the clinician applies pressure to the injection site; when it occurs, it is reported in specific cases to last 7–11 days. When injecting the masseter muscle of the jaw, loss of muscle function can result in a loss or reduction of power to chew solid foods. With continued high doses, the muscles can atrophy or lose strength; research has shown that those muscles rebuild after a break from Botox.
Side effects from therapeutic use can be much more varied depending on the location of injection and the dose of toxin injected. In general, side effects from therapeutic use can be more serious than those that arise during cosmetic use. These can arise from paralysis of critical muscle groups and can include arrhythmia, heart attack, and in some cases, seizures, respiratory arrest, and death. Additionally, side effects common in cosmetic use are also common in therapeutic use, including trouble swallowing, muscle weakness, allergic reactions, and flu-like syndromes.
In response to the occurrence of these side effects, in 2008, the US Food and Drug Administration notified the public of the potential dangers of the botulinum toxin as a therapeutic. Namely, the toxin can spread to areas distant from the site of injection and paralyze unintended muscle groups, especially when used for treating muscle spasticity in children treated for cerebral palsy. In 2009, the FDA announced that boxed warnings would be added to available botulinum toxin products, warning of their ability to spread from the injection site. However, the clinical use of botulinum toxin A in children with cerebral palsy has been proven to be safe with minimal side effects. Additionally, the FDA announced name changes to several botulinum toxin products, to emphasize that the products are not interchangeable and require different doses for proper use. Botox and Botox Cosmetic were given the generic name of onabotulinumtoxinA, Myobloc as rimabotulinumtoxinB, and Dysport retained its generic name of abobotulinumtoxinA. In conjunction with this, the FDA issued a communication to health care professionals reiterating the new drug names and the approved uses for each. A similar warning was issued by Health Canada in 2009, warning that botulinum toxin products can spread to other parts of the body.