This is an article about the differences between anti-wrinkle injectables, namely BOTOX, BOCOUTURE and AZZALURE, the three types of Botulinum Toxin Type A medicines available for cosmetic use in the UK.  For information about wrinkle relaxing treatments at Quayside Medical Aesthetics   please click here.

In the UK patients commonly ask for BOTOX injections for treatment for their lines and wrinkles.  BOTOX itself is the brand name for a specific form of the medicine, rather than the name of the medicine itself, which is called Botulinum Toxin Type A (often abbreviated to BonTA).

BOTOX was the first Botulinum Toxin to be licensed for cosmetic use to treat glabella lines (Frown lines between the eyes) and is therefore probably the most well known, however other Botulinum Toxin Products are also available.  It’s a bit similar to Hoover being synonymous with a vacuum cleaner, when Hoover is just one company that makes a vacuum cleaner.

So is there any difference between them, does it matter which brand is used?

In one sentence, yes there are slight differences and no, it does not matter which brand is used.

Firstly, all the forms contain the active medicine, Botulinum Toxin Type A.  This medicine is a biologically active medicine made by a process called fermentation.  It is produced by a bacteria (clostridium botulinum) and each company that produces the medicine uses the same strain of the bacteria, meaning the active part is identical between different formulations.  The differences between them are in the manufacturing process that extracts and purifies the medicine, and in the excipients (other added ingredients) in the finished product.

I’ll explain how Botulinum Toxin works in nature.  What we currently use as a medical therapeutic agent was historically known for causing food poisoning, botulism.  This is because the bacteria could survive in preserved foods and be eaten by a human host.  The toxin then produced by the bacteria would be absorbed by the human gut and produce it’s effect (muscle weakness, paralysis and ultimately death of the host).  Now this organism is something that has co-evolved with mammals for millions of years and has evolved mechanisms to allow this process to take place.  The human gut is an acidic environment and full of enzymes.  The effect of the human gut environment is not just to break down food into smaller molecules for digestion but also to protect the human from pathogenic organisms (bacteria that can cause disease).  Most bacteria we accidentally swallow will get broken down and destroyed by the acid and enzymes.

So as the clostridium botulinum has co-evolved with us it has evolved it’s own processes to overcome the human gut.  The active molecule or drug that has it’s effect is only a small part of the toxin that is excreted by the bacteria.  The toxin complex is a mixture of the active component, surrounded by a larger number of non active proteins.  These proteins in nature act to allow the active component to survive the process of ingestion and digestion and thus the active part can reach the bloodstream undamaged.

Let’s get back to the differences between the medicines. I mentioned that it is related to the manufacturing process and purification process.  What that means is the different brands, whilst having the same active component, have different amounts of the non active proteins mixed in.The amount of the additional proteins can be measured in terms of the weight of a complex, the complex being the active molecule and its associated proteins.

-For BOTOX the complex weighs  900 kD (kD stands for kilodalton, which is a measure of weight used for molecules).

-For AZZALURE  the medicine seems to be a combination of two different complex sizes, one of 600 kD and one of 300 kD

-BOCOUTURE weighs in at 150 kD, this is the weight of the active component itself meaning that the Bocouture preparation has no additional complexing proteins in the mix, containing only the active compound.

The other difference other than the amount of actual protein, or biological material in the vial is the excipients.  These are other things added to the vial to help maintain the stability of the medicine before it is reconstituted and injected.
BOTOX has added Human Albumin and Sodium Chloride, BOCOUTURE contains Human Albumin and Sucrose, whilst AZZALURE contains Human Albumin and Lactose Monohydrate.None of the excipients have any medical or biological activity.

So there are the differences, what about the similarities?  There have been numerous studies performed to assess the differences between the different preparations, and there is the wealth of anecdotal evidence collected as expert opinion from doctors who have performed thousands of treatments.  The duration of effect has been studied, the side effect profile, the spread, the diffusion, patient and practitioner satisfaction.  So far no significant reproducible difference in the clinical effect between all three preparations has been identified.

Final Summary!

For the patient, there is no significant clinical difference between the formulations, they are all good!

The important thing is to make sure your practitioner is familiar with the formulation they are currently using.  At Quayside Medical Aesthetics we have experience with all three formulations and currently use mainly AZZALURE, we are happy to use another preparation at the patients request however. Products used by Quayside Medical Aesthetics are always sourced through reputable speciality pharmacies.

If you would like to know more about the products we use at Quayside Medical Aesthetics please contact us on 01554 227307 or email: [email protected]

Content of Botulinum Neurotoxin in Botox / Vistabel, Disport / Azzaulre, and Xeomin/Bocouture. Jurgen Frevert, Drugs R D, 2010 jul; 10(2) 67-73

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