BOTOX®

BOTOX® and the Botulinum Toxin Category — What Practitioners Need to Know

Every medical botulinum toxin traces back to the neurotoxin produced by the bacterium Clostridium botulinum. The commercial products, however, are not one substance sold under different labels. Each is a separate biologic with its own international non-proprietary name (INN), manufacturing process, potency assay, and regulatory history. In everyday speech, “Botox injections” has become a catch-all for botulinum toxin injections of any brand, but in clinical and procurement terms BOTOX® means onabotulinumtoxinA from AbbVie and nothing else.

The BTX-A active substances practitioners meet most often are:

• onabotulinumtoxinA: BOTOX® and BOTOX® Cosmetic
• abobotulinumtoxinA: DYSPORT® and AZZALURE®
• incobotulinumtoxinA: XEOMIN® and BOCOUTURE®
• prabotulinumtoxinA: NABOTA® and JEUVEAU®
• letibotulinumtoxinA: BOTULAX® and LETYBO®

BOTOX® was the first botulinum toxin approved by the US FDA, in 1989, for strabismus and blepharospasm [1]. BOTOX® Cosmetic followed in 2002 for glabellar lines, backed by a multicentre Phase III programme in which 20U reduced line severity significantly more than placebo [4]. No other BTX-A has a longer clinical record. BOTOX® and BOTOX® Cosmetic are the same molecule, and “Cosmetic” simply marks the aesthetic approval pathway. BOTOX® Cosmetic is a prescription medicine, just like the therapeutic presentation, and is intended for licensed practitioners only.

For a broader selection, practitioners can buy botulinum toxins from a range of available brands. Those interested in Korean-manufactured products can also buy Korean Botox.

BOTOX® Products — Vial Sizes to Know Before You Buy BOTOX®

BOTOX® Cosmetic 50 Units

This is the standard vial for single-area or small multi-area appointments. Labelled doses are 20U for glabellar lines, the classic BOTOX® frown lines treatment, and 24U for lateral canthal lines, given as 12U per side for BOTOX® around eyes [2]. Reconstituted product should be used within 24 hours, so 50 units of BOTOX® is the sensible format for clinics that run many short appointments, where a larger vial would leave unused units behind.

BOTOX® Cosmetic 100 Units

The 100U vial suits multi-area sessions. A full upper-face protocol at labelled doses (glabellar lines 20U, forehead lines 20U, crow’s feet lines 24U) uses 64U, which leaves room for adjustments from the same vial [2]. It also covers the most recent aesthetic indication, jaw and neck platysma bands, with labelled doses of 26U, 31U, or 36U depending on severity [2]. Clinics that buy BOTOX® wholesale for busy aesthetic lists often standardise on this vial because it usually gives the lowest cost per unit.

BOTOX® (Therapeutic) 100 Units

This is the core therapeutic presentation. The BOTOX® 100 unit vial covers overactive bladder (100U), primary axillary hyperhidrosis (50U per axilla), and blepharospasm, and it also serves as a building block for larger protocols [1]. Chronic migraine calls for 155U across 31 sites, so it is prepared from one 200U vial or two 100U vials [1][3]. Cervical dystonia dosing varies widely. The pivotal study used a mean of 236U, and the label advises a lower starting dose for toxin-naïve patients [1].

BOTOX® (Therapeutic) 200 Units

The BOTOX® 200 unit vial is intended for higher-dose indications. These include urinary incontinence due to neurogenic detrusor overactivity (200U, intradetrusor), severe cervical dystonia, and upper or lower limb spasticity, where adult doses can reach several hundred units [1]. Fewer vials per session means simpler preparation, which is why urology and neurology departments often prefer this size.

Reconstitution, Dilution, and Dosing Reference

BOTOX® is supplied as a vacuum-dried powder. To reconstitute Botox, draw up sterile, preservative-free 0.9% sodium chloride and inject it slowly into the vial. Then rotate the vial gently to dissolve the powder, without shaking it, and record the date and time of preparation. BOTOX® reconstitution volume sets the concentration, since the same 100U vial reconstituted with 2.5 mL saline yields 4U/0.1 mL for standard aesthetic use, 2 mL yields 5U/0.1 mL for the chronic migraine protocol, and 1 mL yields a concentrated 10U/0.1 mL for smaller injection volumes [1][2].

For quick reference, common BOTOX® dilution options include:

Vial	Saline added	Concentration	Typical use
50U	1.25 mL	4U / 0.1 mL	Aesthetic, one or two areas [2]
100U	2.5 mL	4U / 0.1 mL	Standard aesthetic dilution [2]
100U	1 mL	10U / 0.1 mL	Concentrated; smaller injection volumes
100U	2 mL	5U / 0.1 mL	Chronic migraine protocol [1]
200U	4 mL	5U / 0.1 mL	Chronic migraine protocol [1]

At each concentration, the number of units drawn into a syringe follows the graduation on that syringe. At 4U/0.1 mL, a filled 1 mL syringe holds 40U; at 10U/0.1 mL, the same syringe holds 100U. Treatment protocol determines how much is actually prepared.

For a BOTOX® dosing chart, work from the indication-specific tables in AbbVie’s prescribing information [1][2] rather than generic charts, because dose and BOTOX® injection sites differ for each indication. Store unopened vials at 2°C–8°C. After reconstitution, keep the vial refrigerated and use it within 24 hours.

BOTOX® Indications — Aesthetic and Therapeutic

BOTOX® holds four FDA-approved aesthetic indications. These are moderate to severe forehead lines, glabellar lines, crow’s feet lines, and, since October 2024, moderate to severe vertical bands connecting the jaw and neck (platysma bands) [2]. Used this way, BOTOX® shots for wrinkles temporarily improve the appearance of facial wrinkles caused by underlying muscle activity.

The therapeutic label is broader. For chronic migraine, the PREEMPT protocol sets a recommended dose of 155U across 31 sites every 12 weeks. A pooled analysis of 1,384 adults showed a significantly greater reduction in headache days with onabotulinumtoxinA than with placebo [3], and this evidence underpins BOTOX® for headaches and BOTOX® migraine prevention. Other labelled indications include cervical dystonia, upper and lower limb spasticity, primary axillary hyperhidrosis (excessive sweating), overactive bladder, neurogenic detrusor overactivity, blepharospasm, and strabismus [1]. No other BTX-A carries a wider set of FDA-labelled indications, and BOTOX® treatment now spans neurology, urology, dermatology, and ophthalmology.

BOTOX® Compared to Other BTX-A Products

Choosing a BOTOX® alternative starts with two questions: which unit system the product uses, and what it is labelled for.

BOTOX® vs DYSPORT®

DYSPORT® is abobotulinumtoxinA, made by Ipsen and marketed for aesthetics by Galderma. It has a different INN and its own unit system, often called Speywood units. The key difference between BOTOX® and Dysport is that one DYSPORT® unit does not equal one BOTOX® unit. For glabellar lines, the labelled dose is 50U of DYSPORT® against 20U of BOTOX® Cosmetic, a ratio of 2.5:1. Clinical practice generally places the conversion at about 2.5–3 DYSPORT® units for every BOTOX® unit. A review in Toxins found that a ratio of 3:1 or lower suits therapeutic use and that higher ratios risk overdosing [5]. In practical terms, 20U of BOTOX® corresponds to roughly 50–60U of DYSPORT®. Treating the two unit systems as equal is the most common dosing error when switching products.

Beyond units, the BOTOX® vs Dysport comparison comes down to handling. DYSPORT® is often reported to take effect slightly sooner, within 2–3 days. Some injectors also describe a broader field of effect, which can help across the forehead but calls for care near the brow and eyelid. Both products are FDA-approved and authorised in Europe, where AZZALURE® is the aesthetic brand name for abobotulinumtoxinA.

BOTOX® vs BOCOUTURE® / XEOMIN®

BOCOUTURE® and XEOMIN® are the same product: incobotulinumtoxinA from Merz. BOCOUTURE® is the aesthetic brand in the EU and UK, while XEOMIN® is the name used in the US and for therapeutic use in Europe. The defining molecular difference is that incobotulinumtoxinA contains no complexing proteins, whereas BOTOX® does. Units are used 1:1, and clinical data show comparable efficacy and adverse event profiles at that ratio [5]. In day-to-day handling, unopened XEOMIN® vials can be stored at room temperature up to 25°C, while BOTOX® needs 2°C–8°C. Because it lacks complexing proteins, incobotulinumtoxinA may carry a lower theoretical risk of neutralising antibodies over long-term treatment. Both products are FDA-approved with overlapping aesthetic indications, but the BOTOX® therapeutic label is broader.

BOTOX® vs BOTULAX®

BOTULAX® is letibotulinumtoxinA from Hugel in South Korea. The same active substance is sold as LETYBO® in the US and Europe. Like BOTOX®, it contains complexing proteins. The BOTULAX® brand itself has no FDA approval, so product carrying that name cannot be used legally in the US, and its packaging and labelling vary by market. Where it is available, it is commonly dosed 1:1 with BOTOX®. BOTOX® holds the advantage in depth of evidence, with decades of therapeutic and aesthetic data, while BOTULAX® is positioned as a cost-competitive Korean option.

BOTOX® vs NABOTA® / JEUVEAU®

NABOTA® and JEUVEAU® are both prabotulinumtoxinA from Daewoong in South Korea. The product is sold as NABOTA® in Korea and other markets, as JEUVEAU® in the US (Evolus, FDA-approved in 2019 for glabellar lines), and as NUCEIVA® in Europe. Like BOTOX®, it contains complexing proteins. Its labelled glabellar dose is 20U, the same as BOTOX® Cosmetic, and it is generally used 1:1. JEUVEAU® competes mainly on price in the US aesthetic market. The indication gap is significant, though: JEUVEAU® is approved for glabellar lines only, while BOTOX® Cosmetic carries four aesthetic indications alongside the full therapeutic label.

BOTOX® vs LETYBO®

LETYBO® is letibotulinumtoxinA-wlbg from Hugel. The FDA approved it on 29 February 2024 for moderate to severe glabellar lines, based on three Phase III trials with more than 1,000 participants in the US and Europe, and it is also authorised in Europe. It comes in 50U and 100U vials and contains complexing proteins. Its labelled glabellar dose is 20U, matching BOTOX® Cosmetic, so dose planning will feel familiar. LETYBO® is one of the most recent BTX-A approvals, while BOTOX® Cosmetic was the first, in 2002. The main difference is breadth of use: LETYBO® is approved for glabellar lines only, whereas BOTOX® covers chronic migraine, cervical dystonia, limb spasticity, bladder dysfunction, hyperhidrosis, and four aesthetic indications.

Safety and Side Effects

When treatment with BOTOX® is given by trained practitioners at labelled doses, BOTOX® has a well-established safety profile built over more than three decades. Like every botulinum toxin product, it carries a boxed warning for distant spread of toxin effect [1][2]. The most common side effects of BOTOX® are pain at the injection site, bruising, mild swelling, and headache after Botox, and these are usually short-lived. In the original glabellar lines trial, mostly mild eyelid ptosis occurred in 5.4% of treated patients [4].

Serious BOTOX® side effects are rare. Symptoms of distant spread can appear hours to weeks after injection. They include general muscle weakness, double vision, blurred vision, drooping eyelids, and difficulty swallowing or breathing [1]. Some patients also report dizziness within hours of treatment. Other side effects include allergic reactions, urinary retention and urinary tract infection in bladder patients, and dysphagia when the product is injected into muscles of the neck for cervical dystonia [1]. BOTOX® is contraindicated in patients with known hypersensitivity to botulinum toxin and in anyone with an infection at the planned injection site [1]. BOTOX® vs Dysport safety profiles are broadly comparable across the class. Choosing between BOTOX® alternatives should therefore rest on the indication and the practitioner’s familiarity with each unit system.

Where to Buy BOTOX® Online

BOTOX® is a prescription medicine, available only to licensed medical professionals through authorised channels. Whether a clinic plans to buy BOTOX® online for routine restocking or wants to purchase BOTOX® online at a larger scale for multiple sites, the same procurement checks apply. Practitioners who buy BOTOX® wholesale for high-volume aesthetic and therapeutic lists should also confirm they have enough refrigerated storage in place for delivery day.

Before you order BOTOX® online:

• verify that the distributor is authorised to supply the product;
• confirm temperature-controlled shipping, with the 2°C–8°C cold chain maintained throughout transit;
• request LOT number documentation and certificates of authenticity;
• check the licensing requirements that apply in your jurisdiction.

If you want to find BOTOX®, the Medical Spa Rx support staff can advise on verified supplier access, cold-chain shipping requirements, product documentation, and sourcing information. Contact the team to learn more.

Disclaimer

The page and all of its displayed contents are for medical professionals, designed to inform only, and not as a replacement for medical advice.

Citations

[1] AbbVie Inc. “BOTOX® (OnabotulinumtoxinA) for Injection: Full Prescribing Information.” AbbVie, revised Nov. 2023, www.rxabbvie.com/pdf/botox_pi.pdf.

[2] AbbVie Inc. “BOTOX® Cosmetic (OnabotulinumtoxinA) for Injection, for Intramuscular Use: Full Prescribing Information.” AbbVie, revised Oct. 2024, www.rxabbvie.com/pdf/botox-cosmetic_pi.pdf.

[3] Dodick, David W et al. “OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program.” Headache vol. 50,6 (2010): 921-36. doi:10.1111/j.1526-4610.2010.01678.x

[4] Carruthers, J Alastair et al. “A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines.” Journal of the American Academy of Dermatology vol. 46,6 (2002): 840-9. doi:10.1067/mjd.2002.121356

[5] Scaglione, Francesco. “Conversion Ratio between Botox®, Dysport®, and Xeomin® in Clinical Practice.” Toxins vol. 8,3 65. 4 Mar. 2016, doi:10.3390/toxins8030065

Written and reviewed by the Medical Spa Rx Editorial Team 

All clinical and product claims on this page have been checked against peer-reviewed research, manufacturer data, and regulatory sources in accordance with our Editorial Policy .