Risks of erasing wrinkles: Buyer beware!
by Richard Barbano, MD, PhD, FAAN
Many times when one looks back, it is easy to say "it seemed like a good idea at the time." After all, Botox (botulinum toxin type A), has been shown to help erase skin wrinkles. The results have been great. So when a friend offers to get some of it for you, perhaps at much less cost, and even inject it for you, well, that seems like a deal that’s too good to be true. Sometimes it is.
Caveat emptor in Latin means "let the buyer beware." This might be a good subtitle of the article by Dr. Souayah and coauthors in this issue of Neurology (Souayah N, Karim H, Kamin SS, McArdle J, Marcus S. Severe botulism after focal injection of botulinum toxin. Neurology 2006;67:1855–1856). The article tells what happens when someone was treated with an inappropriate preparation of botulinum toxin, apparently by a friend. The results were disastrous.
A 34-year-old woman received botulinum toxin injections for cosmetic purposes. However, the preparation was not the FDA-approved botulinum toxin type A (brand name Botox). The injected substance was apparently research-grade toxin and was bought on the Internet. Two days after the injection, the woman developed progressive shortness of breath, swallowing difficulties, double vision, and generalized weakness. By the time she was examined by a neurologist, she was totally paralyzed with the exception of a little movement of her left big toe. An attempt to limit the paralysis with serum against the toxin was too late and did not help.
Electrical studies of various arm and leg muscles showed them to be totally inactive. Tests showed that the woman had extremely high levels of botulinum toxin in her blood. In fact, the authors of the article estimate that she had been given over 2,000 to 5,000 times the usual amount given for cosmetic purposes!
Botulinum toxin works by interrupting the connections between nerves and muscles. Recovery occurs only when more of the protein that has been inactivated by the toxin is made (see About Botulism). The patient was treated in the intensive care unit for any developing problems while waiting for recovery, which was slow. By 3 weeks, she could only shrug her shoulders and move her eyes. By 5 weeks, she could answer with a yes or no. The last time she was evaluated, 10 months after she was hospitalized, she still had problems with muscle pain and weakness and had some shortness of breath.
Apparently, a second person also received injections at the same time. The authors do not give information about the second person, but hopefully he/she recovered as well as the person described in the article. Although having continued problems with muscle pain and weakness does not sound like a "good" recovery, it must be remembered that botulism has claimed many lives over the last hundred years. Even now, deaths occur.
Botulinum toxin is one of the most poisonous substances known. But when that same toxin is carefully isolated and purified, it can be used as a powerful and effective medication.
Botulinum toxin was first introduced as a clinical tool in the 1980s, and its use has skyrocketed as doctors have applied it to an increasing number of medical conditions. It has revolutionized the treatment of a condition called dystonia. This movement disorder causes involuntary contractions of muscles acting in opposite directions, which results in odd postures and twisting, writhing movements of the neck, trunk, hands, or legs. With periodic injections of botulinum toxin into the muscles most affected, countless patients have been relieved of their symptoms.
Perhaps there is a general misunderstanding that anything that can be used for cosmetic purposes must be easy to use and safe. But just like cosmetic surgery, professional training is a must.
All medications have potential side effects. However, patients need to be aware that when appropriately used by trained doctors, botulinum toxin has a remarkable safety record. The important point is that it should be administered only by someone with considerable experience with the medication. It also must be emphasized that the botulinum toxin used in this sad case was NOT the commercial product found in pharmacies and administered by doctors. This was a research-grade product never meant for medical use in humans. And that is another lesson to be learned from this story, one that has a parallel in a warning of innumerable mothers to innumerable children. Don’t take candy from strangers, and don’t use a medication unless you know where it came from!
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