Dermatologists Identify Individuals Resistant to Botox. Discover If You're Among Them.

Nearly 20 years ago, Dr. Morgan Rabach, while a dermatology resident, worked at one of New York Citys first walk-in Botox clinics on the Upper East Side. Over six years, she administered neurotoxin injections to countless patients, mostly aged 50 to 70, helping reduce wrinkles on the forehead, around the eyes, and between the brows. Many patients returned every three months for routine treatments, often without an appointment, simply stopping by during lunch or whenever convenient.

Over time, Dr. Rabach noticed a small but significant trend: some patients Botox stopped producing results. Its rare, but it does happen, she says. Now a board-certified dermatologist and co-founder of Rabach Aesthetics, Dr. Rabach may have been among the first NYC physicians to observe what many online communities now call Botox resistancea condition where patients experience reduced or no effect from neurotoxin injections.

Meet the Experts

• Dr. Morgan Rabach: Board-certified dermatologist and co-founder of Rabach Aesthetics.
• Dr. Mitchell Brin: Senior Vice President and Chief Scientific Officer for Botox and Neurotoxins at AbbVie.
• Dr. Arash Akhavan: Board-certified dermatologist and owner of The Dermatology and Laser Group in NYC.
• Dr. Debra Jaliman: Assistant Clinical Professor of Dermatology at Icahn School of Medicine at Mount Sinai.
• Dr. Michele Green: Board-certified cosmetic dermatologist in NYC.

Today, Dr. Rabach sees patients who may have developed immunity only once or twice per year. Studies support that true resistance to Botox is extremely rare. A 2023 review of 33 clinical trials involving over 5,800 participants found only five who stopped responding to Botox, and none of those were using it cosmetically. Another 2022 review of 8,800 patients across multiple neurotoxin brands found only 1.8% developed resistance.

How Neurotoxins Work

Botox is commonly used to refer to all neurotoxin injections, though other brands exist, including Dysport, Jeuveau, Xeomin, and Daxxify. Neurotoxins contain botulinum toxin A, which temporarily blocks nerve signals that trigger muscle contraction, reducing the appearance of wrinkles. Different brands vary slightly in formulation, including accessory proteins that may affect how the body responds.

Dr. Brin explains that each brand undergoes a purification process, keeping or removing certain proteins, which can influence how the product works in the body. For example, Botox includes accessory proteins that naturally surround the toxin, while Xeomin contains only the active neurotoxin without additional proteins. These differences may influence diffusion, onset, and duration, though often the distinction is subtle.

Can Immunity Occur?

It is possible but rare. True resistance occurs when the body produces neutralizing antibodies against botulinum toxin A, preventing it from binding to nerves and rendering the treatment ineffective. This type of immunity affects all brands since all cosmetic neurotoxins use botulinum toxin A. Some experts suggest switching brands may restore efficacy due to differences in accessory proteins, though research on this is limited.

Other Factors Affecting Results

Several factors can make injections seem less effective, including:

• Improper dosage: Over-dilution or underestimating muscle strength can reduce results.
• Poor injection technique: Incorrect placement or depth may limit effectiveness.
• Repeated exposure: Frequent or high-dose treatments over years may increase the risk of developing neutralizing antibodies.

Maximizing Botox Effectiveness

Patients can take steps to ensure the best results:

• Choose an experienced injector: Board-certified dermatologists or facial plastic surgeons are preferred.
• Set realistic expectations: Discuss goals and expected outcomes with your provider.
• Track treatments: Record brands, dosages, injection sites, and dates.
• Space out sessions: Wait at least three months between treatments to reduce potential resistance.
• Consider brand switching: If one neurotoxin seems less effective, a different brand may restore results.

Overall, true Botox resistance is extremely uncommon. Most patients can achieve smooth, wrinkle-free results by adjusting technique, dosage, or provider. As Dr. Akhavan notes, claims of widespread resistance are often overstated, and many perceived issues have other explanations.

Author: Sophia Brooks