If you scrape your knee, you probably reach for a Band-Aid. Is a sneeze appropriate? Kleenex, please! Sometimes a brand is so good, so ubiquitous, that it ends up defining an entire industry. The same can be said for Botox.
As you probably already know, Botox is an injectable botulinum toxin. Quick science lesson: Botox is a neuromodulator, a fancy name for a class of chemicals that interrupt signals between nerves and muscles, causing muscles to relax and wrinkles to diminish. “Botulinum toxin injections temporarily inhibit nerve cells that signal certain muscles to contract, thereby weakening facial movements that lead to fine lines and wrinkles,” explains Corey L. Hartman, MD, a board-certified dermatologist in Alabama. Injections are most commonly used to relax the glabellar muscles (commonly known as the 11-fold line) as well as forehead wrinkles and crow’s feet.
Now it gets really technical: Botox comes from a bacteria called Clostridium botulinum, explains Dr. Hardik Doshi is a double board-certified plastic surgeon based in Long Island, New York. The bacteria secretes eight different subtypes of botulinum toxin; type A is considered one of the most potent toxins and the only commercially available form of botulinum toxin available for cosmetic purposes.
We call this botulinum toxin type A because it has the longest track record—it was the first injectable neuromodulator ever—and still has the largest market share. It works so well that other neuromodulators have followed suit, and Botox is no longer the only option. There are currently five FDA-approved injectable neuromodulators: Botox (approved in 2002), Dysport (launched seven years later), Xeomin (approved in 2011), Jeuveau (2019), and the newest drug on the market, Daxxify.
Following Daxxify’s recent approval in September 2022, we decided to investigate what really sets these injectables apart. They all aim to treat the same types of dynamic wrinkles caused by muscle movement, which often appear or are most noticeable when you express emotions. They all contain the same active ingredient, botulinum toxin type A. And they all work the same way, blocking nerve signals to the muscles, which reduces the appearance of wrinkles at the injection site. Ranella Hirsch is a board-certified dermatologist in Boston.
This all raises a lot of questions, like: How do you decide which injection to get? How different are they, exactly? Is it just marketing gimmickry or are some wrinkles, like crow’s feet, easier to eliminate than others? Look, a lot!
To understand what you should know before you see a dermatologist or plastic surgeon, it’s best to know what you should avoid: price comparisons. That’s really not the best place to start. You may have read comparisons that say, for example, that one unit of Botox is equivalent to three units of Dysport, making Botox a more cost-effective option. These analogies are inherently flawed: They assume that providers use the same dilution, which is rarely the case, explains Dr. Deer. It may be perfectly fine to change your focus, she adds. Some doctors prefer more or less diluted medications, and even a single syringe can vary the concentration for different treatment areas depending on the patient’s anatomy. However, since units are not standardized across the industry, a less reputable supplier could, in theory, offer a lower price by using significantly less dilution (and often does), and the consumer would never notice the difference.
No matter which neuromodulator you choose, first things first: It’s crucial to have a vetting doctor (and we really mean doctors, not medical spa aestheticians). It’s the most important thing a patient can do, not only for their safety, but also to ensure the fairest deal and best results. “You need an injector who really masters the muscles of facial expression and has a deep understanding of the effects of different products,” says Dr. Hartman. “It never hurts to check the injector to make sure it’s not overtreating,” he explains. “If the staff and the doctor can deliver in a way that seems natural, you’re probably in good hands. With all the medical spas and substandard injectors out there, it bears repeating: Always make sure your provider is a board-certified dermatologist or plastic surgeon. You can check their credentials at certificationmatters.org.
Now that we know to avoid comparing injections based on price tags and medical spas, we can move on to the main differences between brands: their ingredients, their spread rate (in other words, how much area you can cover with a single injection), how quickly you get results, and how long each effect lasts. Below we break down and compare five neuromodulators on the market.
Botox
Botox is the OG neuromodulator with the longest history and the largest market share. It’s also the only neuromodulator approved for use in all three major treatment areas: between the eyebrows, forehead, and crow’s feet.
Botox, or onabotulinumtoxinA (not a typo), was officially approved for cosmetic use in 2002 for smoothing the vertical lines between the eyebrows (called glabellar lines). It has since been approved for the treatment of crow’s feet (2013). The study, published in the journal Neurosurgery, found that 45% of neuromodulators are approved for use in the treatment of frown lines (2010) and moderate to severe forehead wrinkles (2017), even though doctors have used it off-label in both areas for years. It’s also worth noting that other neuromodulators are only approved for treating frown lines (although doctors also use other brands of neuromodulators off-label), says Dr. Dorsey. Other off-label cosmetic uses for Botox include smoothing the contours of the lips, jawline, and neckline, as well as subtle brow lifts and lip curling (in which botulinum toxin A is injected into the upper lip to slightly “curl” it upward, making the lips appear larger).
After a relatively short downtime (usually mild redness around the injection site lasts 15 minutes to a day), results are seen as early as the third or fourth day, but full effect can take up to two weeks and last two to four months. To maintain results, touch-ups are recommended every three to four months. In addition to its cosmetic uses, Botox can treat conditions such as excessive sweating, chronic eyelid twitching, chronic migraines, urinary incontinence, neck spasms, and other types of muscle spasms.
Most first-time users choose Botox over other neuromodulators, explains Dr. Hartman, though the choice is based more on name recognition and an extensive track record than on different cosmetic benefits. He also says he particularly likes Botox when it comes to brow lifts on both sides of the brow. Its precision means there’s less risk of brow droop (when the brow drops so low below normal that visual impairment can occur).
Dysport
Dysport is known for its spreadability, making it ideal for larger areas like the forehead. It also works a little faster than its competitors, and there’s evidence that it lasts longer, too, making it a popular choice among experienced neurotoxin users.
Dysport, also known as AbobotulinumtoxinA, was FDA-approved in 2009 for temporarily improving the appearance of moderate to severe glabellar lines and treating cervical dystonia in adults (a painful condition in which the neck muscles involuntarily contract and the head twists or turns to the side). Doctors say results typically appear after a few days and can take up to a week to fully take effect, making it difficult to do without. Doft works a little faster than Botox. She says her patients like Dysport the most for this reason, and she feels the same way. “I find it works quickly and lasts just as long as, if not longer than, its competitors,” she says. Dr. Hartman confirms their results, sharing that many of his patients and colleagues who have tried multiple neuromodulators report that Dysport works the fastest and lasts the longest.
What really sets Dysport apart is its spreadability. As Dr. Doshi explains, the special proteins used in Dysport have a lower molecular weight than those used in Botox, which allows Dysport injections to spread through tissues. (Dr. Doft says these proteins primarily serve to stabilize the toxin and improve absorption.) Dysport’s faster spread allows for thorough, even improvement of wrinkles without a heavy feel, adds Dr. Hartman. This is particularly helpful when treating large areas, such as the forehead, as its spreadability allows for full results with fewer injections. “When Dysport is injected into the forehead, it really shines, it spreads well and completely covers this large, flat muscle, allowing for some movement,” shares Hartman. On the other hand, the same spreadability is less beneficial when targeting more precise muscles, such as those around the forehead.
Another potential benefit is reduced oil production in the skin, according to a 2021 study published in the international peer-reviewed journal Toxins. While the study mentions that all neurotoxin injections have the potential to limit oiliness and shine, it suggests that Dysport appears to be best suited for this purpose.
“Dysport is great for reducing sweat and oil production as well as the size of pores,” explains Dr. Doft. “By using small doses of the toxin, it can reduce the production of both of these by affecting the sebaceous glands. “I use it more to reduce sweating in my armpits, hands, and feet.” Hartman reports that he read the same thing about Botox and suspects that if there is an actual effect on oil production, it is likely a class effect, which can be observed with all five neurotoxins on the market. However, Dysport (like all other neurotoxin injections) is not FDA-approved for treating oiliness. Therefore, further research may be needed.
Jeuveau
Jeuveau is one of only two neuromodulators approved for cosmetic use (the other is Daxxify), and has only been on the market since 2019, which means its research and performance history is fairly limited.
The second newest injectable neurotoxin on the market, Jeuveau, or prabotulinumtoxinA, is approved for treating moderate to severe frown lines. According to Dr. Doshi, it’s similar to Jeuveau Botox — a 2019 double-blind, placebo-controlled study found Jeuveau to be just as effective in treating forehead wrinkles. Its key difference, says Dr. Doshi, is that it’s the first neurotoxin developed specifically for cosmetic and aesthetic purposes (whereas its competitors also treat muscle spasms and other conditions).
There’s anecdotal evidence that Jeuveau works faster than other neuromodulators, and in one clinical trial it seemed to work longer for about a third of participants (five months instead of the typical three months). But Dr. Hirsch says the evidence proving it lasts longer or works faster is fairly limited and inconclusive.
Dr. Hartman notes that Jeuveau may actually work better for men than its competitors. Interestingly, Evolus (a brand of Jeuveau) published a peer-reviewed double-blind study in the Journal of Aesthetic Surgery that showed with high consistency that men who received Jeuveau had a higher response rate than those who received Botox. While this is in line with Dr. Hartman’s opinion, it is important to remember a few things: First, the results here were reported by Evolus, not by an independent third party. Due to the small sample size (56 men, 25 treated with Jeuveau and 31 with Botox), the findings also did not reach statistical significance, and further research is needed before firm conclusions can be drawn. Nonetheless, this is still interesting stuff.
Xeomin
Meet the naked neurotoxin Xeomin. While this may not mean much to the average consumer, its unique formula does not contain the same type of protein as other formulas.
Considered by some to be more “natural” due to its lack of stabilizing protein, Xeomin, or IncobotulinumtoxinA, was approved for cosmetic use in 2011 for the treatment of frown lines between the brows. Incidentally, the assumption that it’s purer or more natural due to the lack of these proteins simply doesn’t hold water. The biggest difference between Xeomin and most of its competitors is that it’s stable at room temperature and doesn’t need to be refrigerated before use, which shouldn’t make a difference to the average patient.
While effects are visible after three to four days, Xeomin’s duration of action may be slightly longer than other drugs, with maximum effects after about 30 days. Results generally last about one to three months, says Dr. Hirsch, making it the shortest-acting option, which can actually be very beneficial for first-time patients who might be hesitant about results that last four to six months.
In theory, the lack of additional proteins means that patients are less likely to develop antibodies to Xeomin than to its competitors. Dr. Dorsey. Dr. Dorsey, Hartman, and Dr. Doft are all quick to point out that this is just a theory, not fact. Although Dr. Hartman reports that he’s seen many patients where the effects of Botox wore off and who had better results with Xeomin, he says the results are largely anecdotal. Dr. Hirsch Doft agreed, saying that while she’s heard of some patients becoming less sensitive to Botox or Dysport after years of use, she hasn’t seen this to any significant degree in her practice.
Daxxify
Daxxify, the newest member of the Neuromodulator family, has been grabbing headlines as the longest-lasting new option on the market. Although it won’t be widely available until 2023 (its parent company, Revance Therapeutics, says most people won’t be able to use it until summer), it’s expected to make a splash in the injectable space.
Newly available Daxxify, also known as DaxibotulinumtoxinA, was approved in September 2022 for the treatment of frown lines. Its real selling point is that the effects appear to last longer than any other neuromodulator. In the study that Revance submitted to the FDA, about 80% of participants saw improvements in facial wrinkles after four months of treatment compared with a placebo, and about half saw sustained improvements after six months. Some have even reported results after nine months—results that can translate to one annual appointment (or two biannual appointments) to maintain.
Needless to say, these extended results can be a game-changer, especially for experienced neuromodulator users who may prefer to attend only one or two appointments per year. Keep in mind that most brands recommend refills every three to four months, so the option of two annual injection appointments is very tempting, not to mention that they may be cheaper. Patients can get the same results with half the number of injections.
Daxxify’s staying power comes from its unique stabilizer. Rather than using protein (like Botox, Jeuveau, and Dysport), Daxxify contains a peptide that, according to Dr. Doft, is designed to stabilize the toxin over a longer period of time. According to Dr. Hartman, the peptide is thought to improve absorption, resulting in a more stable binding to neurotransmitters after injection, resulting in a longer-lasting effect.
But that persistence can be a double-edged sword: Because the effects last so long, those who aren’t satisfied with the treatment may have to wait longer than with other injectables to see the effects wear off. Dr. Doft Doft agrees: “This might not be the toxin of choice for a first-time user who wants to try a neurotoxin, but it might be better for someone who knows they like the effects of the neurotoxin and is comfortable with the physician as the injector.”
