Botox vs. Xeomin: The Skinny on Facial Muscle Relaxers

Craig Kraffert, MD

As one of California’s earliest adopters of Botox®, ReddingDerm has been providing Botox Cosmetic services to our patients since 1998.

For many years, Botox owned the cosmetic toxin market for facial muscle relaxers. Recently, however, two new FDA approved market entrants have emerged. The first product, Dysport®, has not been widely adopted because of issues with potency and diffusion. Still, some providers opt for Dysport as it can be more economical, and a few providers actually prefer Dysport to Botox. But Dysport's market share remains small due to comparative performance issues relative to Botox. ReddingDerm has never been a fan of Dysport as there is no compelling reason to offer it in place of Botox.

Last year, Xeomin®, another facial toxin, was released to a few select dermatology practices, including ReddingDerm. We were very excited about this product, as it seemed to offer advantages over Botox without an obvious downside. Xeomin is a much purer botulinum extract than Botox. There are far less inactive proteins in the Xeomin product -- a significant theoretical advantage. It seems logical that a purer product should be better if all else is equal.

Xeomin is manufactured and distributed by Merz, the makers of Radiesse®, a robust dermal filler that we utilize widely at ReddingDerm. Our relationship with Merz gave us the opportunity to exclusively introduce Xeomin, in place of Botox, to our patients last year. During the brief window when this purer new toxin was available, ReddingDerm provided Xeomin treatments to many patients. Soon, however, a legal row between Allergan, the maker of Botox, and Merz resulted in Xeomin being abruptly but temporarily pulled from the US market. Now, a year later, Xeomin is back.

The question is, which facial toxin is better, Xeomin or Botox? The answer: We aren’t sure yet. In our experience, Xeomin appeared to wear off much faster than Botox. It was a real issue for our patients at the time. We are concerned that Xeomin might not be as effective as Botox. Merz is aware of this issue and has recently offered a plausible explanation.

Merz claims that Xeomin needs to be reconstituted more carefully than Botox. Botox is a dried extract that sits at the bottom of the Botox vial. It is easy to predictably reconstitute. Xeomin, on the other hand, is a lyophilized product. This means there tends to be a thin film of product on all parts of the vial, including the stopper. According to Merz, without carefully and thoroughly mixing the product into suspension, as much as 30 to 40 percent of the product can remain in the vial. They further point out that in FDA studies Xeomin was found to not be inferior to Botox.

So, which is it? Does Botox last longer than Xeomin or is Xeomin at least as effective as Botox when properly reconstituted? We are not alone in seeking an answer to this question. Until we know if Xeomin is as good as Botox for our patients, ReddingDerm will be sticking with Botox.

It won’t be long until this conundrum is sorted out. Xeomin has been widely released in its second American market launch and sales are reportedly better than expected. Now it's up to our more adventurous colleagues to answer this question for the benefit of our patients. We will be listening.


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