Comparing Neurotoxins: Botox, Dysport, Jeuveau, and Xeomin

Just as brands like Band-Aid have become synonymous with adhesive bandages, Kleenex with tissues, and Wite-Out with correction fluid, “Botox” has been the colloquial term for botulinum toxin type A (BoNT-A) injections since it was approved by the U.S. Food and Drug Administration (FDA) for the temporary improvement of moderate to severe glabellar lines (i.e. the frown lines between the eyebrows) in April 2002.

But Allergan’s wrinkle smoother isn’t the only BoNT-A injection in town. There is a quartet of cosmetic neurotoxins on the market — Botox®, Dysport®, Jeuveau®, and Xeomin® — that each contain the same active ingredient (BoNT-A) and is FDA approved to treat the same aesthetic concerns.

So, how do you differentiate between the four? The AEDITION is here to help.

How Botulinum Toxin Type A Injections Work

Before we get into nitpicking the differences between Botox®, Dysport®, Jeuveau®, and Xeomin®, it’s important to understand what they are and how they work.

For starters, botulinum toxin type A is the primary active ingredient in each product. And, while BoNT is considered one of the strongest and most lethal toxins discovered to date, small doses of the neuromodulator have the ability to temporarily paralyze muscles for cosmetic effect.

In aesthetic medicine, botulinum toxin is used to reduce the appearance of fine lines and wrinkles caused by facial expressions (think: frowning, squinting, smiling, and the like) by injecting it into the muscles underlying the affected area. In turn, the lack of muscle contraction prevents the face from forming lines and wrinkles.

The result? Smoother skin for three to four months (or until it wears off).

Comparing BoNT-A Injections

Now that you know what Botox®, Dysport®, Jeuveau®, and Xeomin® have in common, it’s time to understand what makes them unique — no matter how subtle the distinctions might be.

“For the average patient, there is no difference between each of the products,” says Jonathan Cabin, MD, a facial plastic and reconstructive surgeon at the Center for Advanced Facial Plastic Surgery in Beverly Hills. “All of the products last a similar amount of time, and they all provide similar results.”

Yes, the comparison is, essentially, apples to apples. But, as any Granny Smith apple fan knows, there is a difference between the tart green ones and, say, a McIntosh. The same logic applies to botulinum toxin injections.

First and foremost, the four injectables are made by different manufacturers, which leads to different costs, potencies, and formulations. While the active ingredient in each product is botulinum toxin type A, some also feature protein blends that may affect the diffusion and efficacy of the injection. Such subtleties are why it is important to find a provider who is well versed in the market.

“Dosage is slightly different for each of the products and the results they offer are subtly different,” Dr. Cabin, who prefers Botox®, shares. “The most important factor is to find a practitioner who is a very experienced injector and is confident using the product you wish to have injected.”

According to the American Society of Plastic Surgeons, the most common side effects of any botulinum toxin injectable are bruising and pain at the injection site, flu-like symptoms, headache, nausea, redness, and temporary facial drooping. While rare, it is possible that the toxin may spread beyond the treatment area, which could lead to botulism-like symptoms including trouble breathing and swallowing, muscle weakness, and slurred speech.

If you’re one of the 7.5 million Americans who received a wrinkle-relaxing injection in 2018 or are looking to join the ranks, here’s everything you need to know about the four FDA-approved BoNT injectables on the market.

Botox®

• FDA Approval: The OG was first approved by the FDA as a temporary aesthetic treatment to improve the appearance of frown lines between the eyebrows in April 2002. It has since been cleared to treat forehead lines and crow’s feet, too (in addition to all its "off label" uses).

• The Skinny: Botox®, or onabotulinumtoxinA, is a product of Irish drugmaker Allergan, and it currently holds an estimated 80 percent of the BoNT-A injection market. With a molecular weight of 900 kDa, Allergan formulates botulinum toxin type A with protective proteins that a subset of patients may develop an antibody against over time, lessening the effectiveness of the treatment. The inactive ingredients in Botox® include human albumin (i.e. plasma proteins) and sodium chloride. There is also a therapeutic version of product that can be used to treat medical conditions like migraines, excessive sweating, and eye spasms (to name a few), but, as it relates to aesthetics, the average cost per unit is around $6 to the doctor and the number of units injected will depend on the area being treated.

• The Results: Botox® is effective but not permanent. It takes about three to five days post-treatment for the results to appear (though it can take up to two weeks for the final effect to be visible), and it lasts about three to four months in most patients. The longevity depends on everything from the way a patient’s body metabolizes the product to the area being treated.

Dysport®

• FDA Approval: Dysport® was first approved to treat frown lines in April 2009, and, like Botox®, also has therapeutic uses to calm muscle spasticity.

• The Skinny: A product of Medicis Pharmaceutical, Dysport® (a.k.a. abobotulinumtoxinA) is slightly less potent than Botox® due to its molecular weight. While both have the same 150 kDa of BoNT-A at their core, the weight of the protective proteins in Dysport® are not uniform like those in Botox®. As a result, Dysport® has a higher rate of diffusion, which makes it ideal for treating larger areas (think: foreheads) — though more product may be needed to achieve results. Nonetheless, the cost is generally comparable to Botox®. Like Botox®, it is formulated with human albumin, and Dysport® also contains lactose and cow’s milk protein — making it unsuitable for patients with milk allergies.

• The Results: While the effects of Dysport® may show up sooner (within 24 hours) than Botox®, some studies have shown that they may not last as long. The shorter lifespan could make it a good choice for patients who are unsure about whether they will like the results of BoNT-A injections.

Jeuveau®

• FDA Approval: The new kid on the block was approved exclusively for cosmetic use in February 2019.

• The Skinny: You may recall the splashy launch party earlier this year that branded Jeuveau® (i.e. prabotulinumtoxinA) as “#NEWTOX.” Maker Evolus is hoping the newbie will prove to be a worthy competitor to Botox®, as they both carry a molecular weight of 900 kDa, are formulated with human albumin and sodium chloride, and offer similar results. But, with a price point 20 to 30 percent less than Botox® and marketing campaigns largely targeted at millennials, it would appear Jeuveau® is seeking to carve out its own patient niche.

• The Results: Clinical data is limited due to the newness of the product, but trials have shown Jeuveau® to have a similar safety and efficacy profile to Botox®. Patients generally begin to see results in three to five days, and they last for three to six months.

Xeomin®

• FDA Approval: Xeomin® was approved by the FDA for the treatment of frown lines in July 2011 (and it has also been medically approved to correct muscle spasticity and, most recently, excessive drooling).

• The Skinny: Merz-made Xeomin® (a.k.a. incobotulinumtoxinA) is unique in that it does not blend BoNT-A with complexing proteins (though inactive ingredients include human albumin and sucrose). As a result, the neurotoxin doesn’t need to be refrigerated and it may be slightly more comfortable to have injected because it is stored at room temperature. Xeomin® generally costs about the same as Botox® and Dysport® — but fewer units may be needed to achieve the desired result. Patients who show signs of resistance to Botox® and Dysport® may find success with Xeomin® due to the purified state of BoNT-A.

-The Results: Results from Xeomin® injections take five to seven days to become visible and last a similar amount of time to Botox®, Dysport®, and Jeuveau®.

The Takeaway

As you can see, each of the four neurotoxins have similar safety and efficacy profiles, but subtle differences do exist that may make one a better option for your particular needs. While nothing can replace a consultation with a board certified dermatologist or plastic surgeon, here are the key takeaways for each botulinum type A injectable.

Botox®

• Benefits: Good for treating all areas — especially small ones (think: crow’s feet) -Onset: 3-5 days
• Results: 3-4 months
• Average Units: 20 for forehead treatment
• Drawbacks: Patients may develop antibody resistance over time

Dysport®

• Benefits: Good for last-minute treatments because of faster onset time; ideal for treating larger areas (i.e. the forehead) because of diffusion
• Onset: 24 hours
• Results: 3-4 months
• Average Units: 50 for forehead treatment
• Drawbacks: Not suitable for small areas or patients with an allergy to lactose or cow's milk protein

Jeuveau®

• Benefits: Cosmetic nature eases government pricing regulations, which may lead to more affordability
• Onset: 3-5 days
• Results: 3-4 months
• Average Units: 20 for forehead treatment
• Drawbacks: Newest to market, so long term safety and efficacy profiles have not been established

Xeomin®

• Benefits: Ideal for patients who have stopped responding to Botox® or Dysport®
• Onset: 5-7 days
• Results: 3-4 months
• Average Units: 20 for forehead treatment
• Drawbacks: Longer onset time