Botulinum neurotoxin (BoNT) is a protein produced by gram-positive anaerobic bacteria Clostridium botulinum in seven serotypes (A, B, C, D, E, F, G). BoNT is a potent and neurospecific toxin, with limited tissue passage and its action wears off over time. BoNT has been approved for treatment of strabismus and blepharospasm, severe axillary hyperhidrosis, chronic migraines, moderate to severe glabellar lines, lateral canthi lines and forehead lines. Many clinical studies and case reports describe the off-label use of BoNT for sweat, pain and pruritus reduction, hair growth and other cosmetic purposes. It is effective in treating bromhidrosis and malodor, chromhidrosis, craniofacial hyperhidrosis, eccrine nevus, Frey's syndrome, focal anal hyperhidrosis, granulosis rubra nasi, hidradenitis suppurativa, inverse psoriasis, palmoplantar hyperhidrosis and pompholyx. BoNT reduces pain in patients with anal fissure, bruxism, cutaneous leiomyomas, erosive lichen planus, Fox-Fordyce disease, frostbite neuralgia, granular parakeratosis, lichen simplex chronicus, neuropathic scar pain, postherpetic neuralgia, Raynaud’s phenomenon, and vulvodynia. It is effective against brachioradial pruritus, burn-induced pruritus and histamine-induced pruritus. For cosmetic enhancement, it was applied for elimination of décolleté wrinkles, facial asymmetry/synkinesis, erythema and flushing, gummy smile, leonine facies, pectoral muscle contraction, oily skin, enlarged pores and numerous hypertrophies (of gastrocnemius muscle, masseter muscle, temporal muscle, trapezius muscle and salivary gland hypertrophy). It is also effective in scar prevention and treatment. It's use was successful in treating androgenetic, cephalalgic and radiation-induced alopecia and folliculitis decalvans. Moreover, studies have shown its effectiveness in treating apocrine and eccrine hidrocystomas, aquagenic keratoderma, Darier's and Hailey-Hailey disease, epidermolysis bullosa simplex, linear immunoglobulin A bullous dermatosis, plaque psoriasis, and pachyonychia congenita. To have the use of BoNT approved, harmonization of treatment protocols and standardization of dilutions, dosing, timing and injection techniques have to be achieved.
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