Praised by many as the ultimate elixir of youth, botulinum toxin has been gracing the foreheads of Hollywood royalty, models and more for many years. First pioneered by aesthetic physicians in North America over 25 years ago, the rising affordability of the treatment, paired with improved techniques, has resulted in women from the boardroom to the locker room visiting clinics to wipe away the years.

At its inception, the toxin was mainly known for treating serious motor conditions, such as cerebral palsy in the lower limbs or partially blind patients suffering from severe blepharospasm. Now, neurotoxins are the number one aesthetic procedure in the United States, remaining the gold standard in the quest for eternal youth.

The toxin, which is used to treat the upper as well as lower face, is also regarded as a multi‑faceted weapon to improve the appearance of scars and skin conditions, including acne and rosacea. And if that wasn’t enough, new studies suggest it could also be a successful treatment for mild depression in some.

The discovery of the toxin

Botulinum toxin, a purified protein derived from the bacterium Clostridium botulinum, was first identified in 1895. There are different variations of C. botulinum (A, B, C, D, E, F and G). OnabotulinumtoxinA (Botox; Allergan, Irvine, California, USA) contains tiny amounts of highly purified botulinum toxin protein refined from the bacterium.

Oculinum was first approved by the US Food and Drug Administration (FDA) in 1989 to treat strabismus and blepharospasm in those aged 12 years and older. In 1998, botulinum toxin A (BoNTA) was approved for lower limb spasticity in cerebral palsy, followed by approval for severe primary axillary hyperhidrosis in 2001. In fact, it was only in 2002 that the toxin was approved for cosmetic use to improve the appearance of moderate to severe glabellar frown lines in people aged 18–65 years. However, that doesn’t mean that aesthetic physicians waited until 2002 to use the toxin in practice. The panel of experts interviewed for this article, who are among the leading neurotoxin pioneers for cosmetic indications, have been using it as early as 1987.

Dr Jean Carruthers hasn’t frowned since 1987 when she started to use neurotoxins on herself. This was, at the time, the only way to persuade her patients that it was safe to use on the face. ‘Look what it does to me,’ she would tell her patients. And they liked what they saw.

The fact that the toxin was approved for patients up to 65 years of age does not relate to how physicians are using it today, however. Ageing baby boomers nearing their 70s are now living longer and want to stay youthful-looking until the end of their lives. BoNTA is being used in highly successful practices in women in their 80s and even their 90s, according to the doctors interviewed for this article. It is being used differently, often in higher doses, and in synergy with other injectables.

A more recent approval for the toxin in 2010 is for patients suffering from chronic headaches at least 15 days per month, of which at least 8 days are migraines. BoNTA is still one of the most researched drugs: over $300 million in R&D investment, more than 2500 peer‑reviewed articles, and approximately 65 clinical trials involving 15000 patients. Over the past 20 years Botox has been approved in 80 countries for 21 different indications, and only one for cosmetics at this point. Botox has been joined by other neurotoxins, such as Dysport/Azzalure (Q-Med, A Galderma Division, Uppsala, Sweden) and Xeomin/Bocouture (Merz Aesthetics, Frankfurt, Germany), and it is expected that more will arrive on the market over the next year.

Beautiful, untroubled expression

Over the past 20 years, the perception of BoNTA treatment has changed a great deal. From a simple forehead line relaxer, it is now seen as a pick-me-up, with many patients reporting increased happiness, relaxation, and even greater professional success. By preventing the ability to frown, patients believe they are sending a better message, giving them a sense of positivity — a valuable tool in today’s challenging workplace.

The toxin is now being studied as a potential tool to treat mild depression. A new generation of physicians believes that the neurotoxin might be a safe and potentially effective way to help millions of people who are not responding well to pharmacological and psychotherapy treatments. In the recently published The Face of Emotion: How Botox Affects Our Moods and Relationship1, author Eric Finzi suggests that up to half of all wrinkle-busting procedures can dramatically improve mood, as well as our relationships with others. His study, with Dr Erika Wasserman, evaluated 10 clinically depressed patients who had never received any Botox injections. Two months after receiving treatment with botox, patients reported a dramatic decrease in their feelings of depression. Although based on a reduced sample group, this study is showing promise for the manifold applications of the toxin. Extended and larger clinical trials should be carried out to verify the therapeutic effects of neurotoxins in fighting depression, as more physicians report a feel-good effect in patients following injection.