Home' Australian Pharmacist : Australian Pharmacist July 2014 Contents Australian Pharmacist July 2014 I ©Pharmaceutical Society of Australia Ltd.
CONTINUING PROFESSIONAL DEVELOPMENT
feet and nasolabial lines. The effects
last between three and four months,
after which time the improvements are
almost completely gone.18,19 Hence, to
maintain the reduction in appearance of
facial lines, most patients require around
three treatments per year. It should be
noted that good technique is essential
for optimal results and safety, so patients
should carefully assess the qualifications
and experience of the clinician.
Botulinum toxin is safe and effective when
used by well-trained, experienced clinicians.
Adverse effects are typically transient and
mild-moderate in severity. After injection,
botulinum toxin diffuses into the muscles
and other tissues and its effects diminish
as it moves further from the injection site.
When used to reduce the appearance
of facial lines, adverse effects include
headache, blepharoptosis (drooping upper
eyelids), facial pain, oedema at the injection
site, nausea, ecchymosis (bruising) and
erythema. These effects tend to be mild
and transient and generally abate within
1--2 weeks. Adverse effects appear to
decline with successive treatments, possibly
related to improved injection technique
and/or the development of tolerance. In the
longer term, botulinum toxin treatment
for reducing the appearance of facial lines
appears to be safe and well tolerated.20
In one study of 945 botulinum treatment
patients who had received treatment
for 3--5 consecutive cycles, 91% patients
reported no adverse effects.20
Contraindications to botulinum toxin
include known allergy, presence of
inflammation or infection at the injection
sites, pregnancy and breast feeding, and
presence of neuromuscular disorders
(e.g. myasthenia gravis). Aminoglycosides
and curare-compounds may interfere with
neuromuscular transmission and potentiate
the effects of botulinum toxin. The potential
for interaction with these drugs may
persist for 3--6 months after administration
of botulinum toxin. Anticoagulants may
increase the risk of bruising post-injection,
but do not necessarily preclude the use of
the toxin for cosmetic reasons.
The psychological effects of botulinum
toxin for cosmetic reasons are interesting.
A case series involving 10 patients found
that botulinum toxin Type A improved
symptoms of depression.21 Further research
confirms that the toxin may have beneficial
effects in patients with depression.22
Other research suggests that botulinum
toxin can dull the ability to read emotion in
others,23 on the basis that facial expressions
provide powerful cues to our thoughts and
emotions. It is thought that we decode each
other's expressions, in part, by simulating
the perceived expression in our own facial
musculature. There certainly appears to
be more to learn about the positive and
negative effects of botulinum toxin on
mood, psychological state, self-perception
and perception by others.
The pharmacist's role
Several procedures may improve facial
appearance, including laser therapy,
dermabrasion, botulinum toxin and
the use of skin fillers. In this case,
the pharmacist could provide advice
regarding the potential costs, potential
adverse effects and the temporary
nature of benefits associated with
botulinum toxin injections. They could
also encourage the patient to talk to
their GP or local aesthetic centre about
the available options. People who are
considering the available techniques
should understand and costs, risks and
the temporary nature of the benefits.
The pharmacist could also provide advice
on some simple strategies to reduce the
progression of photo-ageing. Protection
from the sun at any age reduces the
risk of actinic keratosis, squamous
cell carcinoma and progression of
photo-aging.2 In animal studies, the
use of sunscreens has been shown to
repair pre-existing damage and prevent
further damage by exposure to UV
radiation.24,25 In humans, the use of
sunscreen has been shown to stabilise
changes in the skin compared to a control
group, where photo-ageing of the skin
increased.26 Daily use of sunscreens
also significantly reduces the incidence
of actinic keratosis and squamous cell
carcinoma.27,28 If Mrs Johnson is not
already doing so, daily application of an
SPF 15 or higher sunscreen is likely to be
beneficial. Although sunscreens almost
entirely block the synthesis of vitamin
D3 theoretically, in practice they have
not been shown to do so.29,30 Regular
sunscreens users tend to have sufficient
exposure to the sun to allow adequate
vitamin D production. Obviously,
Mrs Johnson should avoid tanning
and understand the link between the
sun, photo-ageing and facial wrinkling
and lines. Cosmetic preparations that
contain low concentrations of hydroxyl
acids (e.g. glycolic acid, lactic acid) may
also have a small benefit in improving
skin roughness and pigmentation.31.32
It is worth noting that skin treated with
hydroxy acids admits more UVB radiation
(about 20%) than untreated skin, so
a concomitant sunscreen is essential.
Topical retinoids may also reduce the
severity of photoaging,33,34 although they
are not indicated for this use in Australia.
Botulinum toxin Type A is a widely used,
effective and safe treatment for reducing
the appearance of facial lines. However,
the effects are temporary, requiring at
least 2--3 treatments per year to maintain
the benefits in appearance.
1. Leveque JL. Quantitative assessment of skin aging. Clin
Geriatr Med 2001;17:673--89, vi.
2. Stern RS. Clinical practice. Treatment of photoaging. N Engl J
3. Malvy J, Guinot C, Preziosi P, et al. Epidemiologic
determinants of skin photoaging: Baseline data of the su.Vi.
Max. Cohort. J Am Acad Dermatol 2000;42:47--55.
4. Kennedy C, Bastiaens MT, Bajdik CD, et al. Effect of smoking and
sun on the aging skin. J Invest Dermatol 2003;120:548--54.
5. Yaar M, Gilchrest BA. Photoageing: Mechanism, prevention
and therapy. Br J Dermatol 2007;157:874--87.
6. Arnon SS, Schechter R, Inglesby TV, et al. Botulinum
toxin as a biological weapon: Medical and public health
management. JAMA 2001;285:1059--70.
7. Cherington M. Clinical spectrum of botulism. Muscle Nerve
8. Aoki KR, Guyer B. Botulinum toxin type a and other
botulinum toxin serotypes: A comparative review of
biochemical and pharmacological actions. Eur J Neurol
2001;8 Suppl 5:21--9.
9. Eleopra R, Tugnoli V, Quatrale R, et al. Different types of
botulinum toxin in humans. Mov Disord 2004;19 Suppl
10. Meunier FA, Schiavo G, Molgo J. Botulinum neurotoxins:
From paralysis to recovery of functional neuromuscular
transmission. J Physiol Paris 2002;96:105--13.
11. Walker TJ, Dayan SH. Comparison and overview of currently
available neurotoxins. J Clin Aesthet Dermatol 2014;7:31--9.
12. Scott AB. Botulinum toxin injection of eye muscles to correct
strabismus. Trans Am Ophthalmol Soc 1981;79:734--70.
13. Burgen AS, Dickens F, Zatman LJ. The action of botulinum
toxin on the neuro-muscular junction. J Physiol
EVIDENCE IN PATIENT CARE
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