A couple of times a year, I’ll see a reader email us this question, or a friend will shoot me a text: “I feel like my Botox isn’t working anymore. Am I becoming immune to it?” If this has ever happened to you, you’re not crazy—it is possible. For some people, their line-smoothing neurotoxins (they work to temporarily paralyze the muscles that contract and cause wrinkles) “stop working” over time. We’ve got the inside scoop from the experts on the reasons why, and what to do if it happens to you.
You’re Getting Injected Too Often
According to New York dermatologist Doris Day, MD, because of the way the neurotoxins are processed, the more you are exposed to it, the more likely you are to build up a resistance. “If you get a treatment and then wait three months, the drug is completely out of your system and has completely worn off, so the next time you get it, it’s like getting it for the first time,” she explains. “People who get ‘Baby Botox’ more often—fewer units every four to six weeks—are increasing their risk of building their immunity to the neurotoxin. And it’s not that they want to look frozen, but some people may benefit from treatments more often to get the look they want. However, if you keep getting it over and over in less than two-month intervals, you’re more likely to build up a resistance. The way to minimize the issue is to make sure you space your treatments out every three to four months.”
The only product on the market that the resistance wouldn’t occur with is Xeomin, Dr. Day says. “All the other neurotoxins available in the U.S. are formulated with binding proteins, but Xeomin is the only pure form of the drug without any other elements that might create an antibody response. I think Xeomin works great, and in my hands, I use it very precisely and get fantastic results. I can also modify the treatment based on the patient’s goals.”
New York dermatologist Julie Russak, MD, agrees, saying the body can develop antibodies to a specific product and your immune system will resist it. “In most cases, people build up antibodies to the accessory protein in Botox Cosmetic and Dysport, rather than the active molecule. If this happens, we can switch to Xeomin, which doesn’t contain this specific type of protein.”
What most patients don’t realize, says Los Angeles facial plastic surgeon Kimberly J. Lee, MD, is that there are different strains of Botulinum toxin, with Botulinum toxin A being the most common type for cosmetic use. “It’s become significantly harder to get the other strains of botulinum toxin, so if one type of neurotoxin doesn’t work, many times a competing brand’s neurotoxin will,” she explains. “Even if it’s the same strain of botulinum toxin, there are some nuances that work better with some patients more than others. There are also some other reasons why an injector would choose one type of botulinum toxin over another so it’s best to consult with an expert who can guide you to achieving the results you seek.”
With all this being said, however, Dr. Day says she doesn’t see this “immunity” happen very often. “In the 20-something years I’ve been using Botox and other products, it’s not often that I see this problem. But, we are now starting to use these products a lot more often in the form of ‘Baby Botox,’ so I do think we’ll start to see more of this problem.”
You’re Part of the 4 Percent
Dr. Lee says patients can be resistant to neurotoxins entirely. “Approximately 4 percent of the population is resistant to neurotoxins, meaning they have no effect from the injection.”
It May Be the Result of Natural Aging
According to Purchase, NY plastic surgeon Michael Suzman, MD, there’s a possibility that the neurotoxin is still working, but you’re perceiving it differently after many years of getting injected. “If a patient sees a lessened effect after receiving their regular injections, it may be because they are so used to the smooth look they have achieved, but still continue to age normally over time, and therefore see less of a ‘youthful’ result,” he explains.
You Didn’t Go to an Expert Injector
Neurotoxins have been around for decades and are super quick to administer—my forehead and glabella take less than five minutes total—but that doesn’t mean they shouldn’t be considered a serious procedure. Injecting anything in the face should be left to a board-certified dermatologist or plastic surgeon, or a qualified injector. “Another reason someone might think their neurotoxins aren’t working is if the injection missed the strongest part of the muscle and concentrated between areas of muscle where it is less effective,” says Dr. Suzman. “A touch-up with product from a fresh vial should correct the issue.”