Is it possible to become immune to anti-wrinkle injections?

Article medically reviewed by Dr. Gavin Chan (MBBS, cosmetic physician, liposuctionist)

Dr. Gavin Chan

Templestowe Lower and Berwick Clinics

Dr. Gavin Chan has a background in intensive care, anaesthesia, and emergency medicine. Since 2004, Dr. Chan has provided cosmetic procedures, including anti-wrinkle injections, dermal fillers, liposuction, fat transfer, skin needling, and laser treatments. He is a doctor trainer for various dermal fillers and anti-wrinkle injections.
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Did you know that anti-wrinkle injections are one of the most popular cosmetic
treatments in the world?

Apart from treating fine lines and wrinkles on your forehead,
crow’s feet and frown lines, they can also be used to treat many medical conditions
and neurological conditions such as:

  • Excessive underarm sweating
  • Facial spasm
  • Cervical dystonia (involuntary neck muscle contraction)
  • Headaches and migraines
  • Bruxism or jaw clenching.

Since anti-wrinkle injections are mostly used for cosmetic purposes, if they didn’t
work after a while, these people would be devastated. Dr. Gavin Chan (MBBS,
Cosmetic Physician, Liposuctionist) in a recent YouTube video points out that most
people have it once and because of the ‘magical results’ end up having it regularly
for the rest of their life. With COVID-19 having closed many cosmetic clinics down, a
lot of people have been missing out on their regular anti-wrinkle injections. Dr Gavin
Chan notes, “for many people, it can be quite devastating to have those fine lines
and wrinkles come back once the anti-wrinkle injection treatment wears off. But
there’s something else that may be stopping us from enjoying the wrinkle-reducing
effects of anti-wrinkle injections – and that’s our immune system.”

How you may develop immunity to anti-wrinkle injections

Your immune system protects you from viruses and bacterial toxins in the outside
world by producing antibodies which provide you with immunity from future attacks.
Dr Gavin Chan explains, “since anti-wrinkle injections are a bacterial toxin, then it’s
possible that our immune system will defend us from it. If your body is building
immunity to anti-wrinkle injections, this would be highly undesirable, especially given
the nature of anti-wrinkle treatment is to have it done every three to four months.”

So why aren’t other cosmetic practitioners talking about this? Dr Gavin Chan thinks it
may be because it’s rare for anti-wrinkle injections to not work at all. However, it’s not
uncommon for anti-wrinkle injections to only work partially.
If you get regular anti-wrinkle injections, you’ve probably had a treatment where you
didn’t get the exact result you wanted. From more facial movement than you normally
get to the treatment not lasting as long. Dr Gavin Chan explains, “I’ll be the first to
admit that despite practising cosmetic medicine for 15 years, I’ve spent most of those
years in denial about the possibility that my patients are becoming immune to anti-
wrinkle injections. Then I came across a small handful of patients who despite
topping up their anti-wrinkle injection dose, despite doubling the dose and despite
multiple attempts at trying to get their anti-wrinkle injections to work – nothing
happened. It didn’t work at all. Their muscles fully contracted afterwards.”

This realisation that a handful of patients may be partially resistant to anti-wrinkle
injections prompted Dr Gavin Chan to find out more. “The only way to know if you’re
developing a degree of resistance or partial resistance or immunity against anti-
wrinkle treatment is to do a blood test to detect neutralizing antibodies. The only
place I could find in the world to do this test was a place in Germany called Toxogen.
I actually emailed them with the view of sending them samples from my patients to
test. Financially it was very costly and the feasibility of sending blood there was low
due to the fact that you needed cold storage transport.”

It’s not possible to easily perform a test for the antibodies or determine the
percentage of patients who develop neutralizing antibodies with anti-wrinkle
treatments in Australia. But a German study “High prevalence of neutralizing
antibodies after long-term botulinum neurotoxin therapy” by Professor Phillip Albrecht
had access to the Toxogen laboratory. This significant study showed that 13% of 596
patients of those treated with anti-wrinkle injections formed neutralizing antibodies
against the botulinum toxin when used for neurological conditions such as:

  •  Blepharospasm
  •  Cervical dystonia
  • Facial hemispasm
  •  Spasticity and dystonia.

Dr Gavin Chan notes, “there are some neurological conditions used in the Albrecht
study that are very similar to the cosmetic treatments that we perform including blepharospasm or twitching of the eye muscle. This is also similar to treating crow’s
feet with similar doses of anti-wrinkle injections. I believe it’s likely that resistance is
an issue with cosmetic anti-wrinkle injections as well treatment’s for neurological
concerns.”

Anti-wrinkle injections: why the one without complexing proteins may be
more suitable for you

Anti-wrinkle injections work to restrict or prohibit muscle contraction. To unravel the
underlying causes of immunity to anti-wrinkle treatment, it’s important to look at the
bacterial toxin more closely. In Australia, there are 3 brands of botulinum toxin. Two
of the 3 brands have the active part the neurotoxin but also have an associated
complex protein which are not involved in the function of the botulinum toxin itself.
These brands with the active neurotoxin and complex proteins are actually a risk
factor for developing immunity. They can often trigger the immune system leading to
the formation of antibodies both to the complexing protein and the active neurotoxin.
If this happens, it renders the anti-wrinkle treatment ineffective. Over the past few
years, a third brand of botulinum toxin has become available in Australia. This brand
is purified and doesn’t contain the complexing proteins. Dr Gavin Chan recently
interviewed the inventor of this anti-wrinkle injection brand, Dr Jurgen Frevert,
Scientist and Botulinum Toxin expert. With decades of experience working with
botulinum toxins, he’s the ideal person to ask about why complexing proteins are
contained in some botulinum toxin products.

Dr Gavin Chan: “As the inventor of this botulinum toxin, which is purified free of
complexing proteins, maybe you could tell us a bit about what led you to create this
botulinum toxin?”
Dr Jurgen Frevert: “Well, in 1990 I became an advisor to the company Allergan
(which manufacturers one brand of anti-wrinkle injection). They were interested in my
work because I’m a specialist in botulinum toxin. At that time, the company didn’t
have experience with proteins and biologicals, so they approached me. The anti-
wrinkle injections are based on the botulinum toxin complex that means not only the
active substance, the neurotoxin, but also the complexing proteins. I didn’t understand why they had these bacterial
proteins in the anti-wrinkle treatment because it’s not a necessary part of the
botulinum toxin to stay active.”

Dr Gavin Chan: “So the complexing proteins do nothing in terms of the activity of
botulinum toxins? If this is the case, why has it taken us so long to get to this point
where manufacturers are only now or only since you invented another anti-wrinkle
injection have we decided to make a purified toxin? Why hasn’t this been done from
the beginning and what do you think are the reasons?”
Dr Jurgen Frevert: “The thing was that the complex proteins are necessary for the
stability of the neurotoxin. It was thought that the neurotoxin is immediately degraded
and denatured after dilution, after formulation, after drying and that’s why Allergan
stuck with this. I was pretty convinced that it is possible to develop a new toxin
without the complex proteins and in the end, we found an optimal formulation which
really stabilizes the new toxin. This anti-wrinkle treatment is the only product on the
market like this that’s stable at room temperature. So, it’s really possible to develop a
new toxin without the complexing proteins. The complexing proteins are absolutely
useless.”
Dr Gavin Chan: “So if that is the case and as Cosmetic Doctors and Cosmetic
Nurses, how can we ethically justify giving our patients a botulinum toxin with protein
in it, knowing that it will likely or have some chance of causing some degree of
immunity?”
Dr Jurgen Frevert: “From my thinking it’s not really justified to inject complexing
proteins which have no function in the mechanism of action, which have no function
at all in the therapy of botulin toxin. Why inject patients with unnecessary proteins
which are not an advantage for the patient?”
An important point to take from this interview is that if patients develop antibodies
against the anti-wrinkle product, it’s not possible to treat these patients because the
antibodies latch onto the neurotoxin and prevent the uptake of the new toxin by the
nerve cells. To listen to Dr Gavin Chan interviewing Dr Jurgen Frevert, head here.

So unless you want to have an occasional break from your anti-wrinkle treatment every
once in a while, it’s better to use a brand that is purified free of complexing proteins.
This will help reduce your risk of immunity to the treatment. To keep your fine lines
and wrinkles at bay, you’ll need to have many anti-wrinkle injections in the long term.

Dr Gavin Chan believes it’s all about consistency and being able to count on the fact
that your anti-wrinkle treatment will be as effective now as in a few years’ time. Since
we can’t test for the presence of antibodies or immunity easily, it’s a good idea to
prevent this occurring by asking to be treated with this anti-wrinkle injection brand.
Before you book an appointment for your anti-wrinkle injections, it’s important to
consider the following:

  • Does the clinic have a good reputation for delivering natural-looking anti-
    wrinkle injection results?
  • Does the clinic offer the anti-wrinkle injection brand that does not contain
    complexing proteins?
  • Have the Cosmetic Doctors and Cosmetic Nurses got advanced injection
    techniques?
  • Does the clinic offer a follow-up review and complimentary top-ups if
    required?

Dr Gavin Chan and his team of highly trained and experienced Cosmetic Doctors
and Cosmetic Nurses have been treating patients with anti-wrinkle injections since
2005. Call our helpful and friendly customer service team today to book your anti-
wrinkle injection treatment 1300 863 824.

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