A New Facial Expression to Botox

Delayed Hypersensitivity Reaction to OnabotulinumtoxinA

“…As in the current case, rare idiosyncratic responses to botulinum toxin have involved prominent swelling and other features suggestive of anaphylactoid reactions . However, interpreting the prior reports of similar outcomes has been confounded by co‐administration of other medications, including lidocaine, prilocaine, and fentanyl together with midazolam . The only reported case of an immediate severe (and ultimately fatal) anaphylaxis after onabotulinumtoxinA injection was associated with the unapproved practice of reconstituting the freeze‐dried neurotoxin using 1% lidocaine solution.…”

“…Compared to albumin, the quantity of botulinum toxin is far less, though sufficient for initiating immunological responses that include the generation of neutralizing antibodies and the clinical outcome of blocked denervation effect . In some instances, patients experiencing hypersensitivity reactions (including ours) had past exposure to the drug, though in two cases, they occurred following its initial use …”

“…The safety of botulinum has been established in the extensive reporting and meta‐analysis of adverse events over almost three decades since the drug's FDA approval in the U.S . Several publications have documented rare occurrences of sudden or sub‐acute adverse effects that appear to be immunologically‐mediated (and in several instances, strongly suggestive of anaphylactic reactions) . In some reports, localized swelling reactions developed immediately or within a few hours after injections with botulinum toxin‐type A.…”