Episode 5: Daxxify, Botox, Dysport, Xeomin, Jeuveau

Daxxify, the new 6 month toxin is coming to market.  How does it compare with the current toxins?  What are the differences between Botox, Dysport, Xeomin and Jeuveau?  
The next 6-9 months will give us a greater amount of information on how to best utilize Daxxify and how practitioners can incorporate this into their practice. 

Thank you for your listenership!

Transcript

 Dr. Saluja
 Hi everyone. I hope you're well. Thank you so much for joining in on the next episode of just Laser IT and all Things Cosmetic and I am here with Kane and with Link. And how are you doing Kane? 

Kane: I'm doing great, thank you. 

Dr. Saluja: Well, today I'm actually very excited to do this episode
The reason why I'm excited is because we, we are gonna talk about something that is a disruptor. And what I mean by that is, the toxin market has been around for over 30 years. When we talk about the cosmetic use of toxin and yes, new toxins have been added and we love them all, but this is the first toxin that is actually a six month toxin.

Kane: And when you talk about toxins, we're talking about the Botox, Dysport of the world?? 

Dr. Saluja: Yes, and we're going to go through each one of those. And so let's,  that's what we're going to  talk about today. We're going to talk about a little history of toxin. I'm going to talk about the four current toxins that are on the market, and then we'll end with this new toxin, which is Daxxify, which is the six month toxin.

Kane: Which could possibly be a disruptor in the market? 

Dr. Saluja: Possibly be a disruptor, and I will play devil's advocate with it when we talk about it, just to kind of ask the questions that we will be asking and evaluating over the next six months.

Kane: Okay. Well, and I will say before you start is, you know, I was always hesitant to try Botox or Dysport and when I finally did it, I'm glad I did and I mention it because as a man, I was unsure and when I got it, I just felt refreshed and younger and it just made a big difference.

 Dr. Saluja: Haha! You have got to listen to me when tap your other shoulder, say sit in that chair, we have to inject toxin no, I'm glad you did too. But you know, you bring up a good point. The male market is  becoming a huge market too. When I did my fellowship, males were probably 5% of the population that came into the clinic. Now, I think it's about,  15, 20%.  Females certainly still are, our primary patients, but I think the male market for sure is, is getting larger.

Let's start with how toxin came about and I will keep this short. 
So Dr. Jean Caruthers who is an  ophthalmologist and was in her ophthalmic clinic and was treating patients with hemifacial spasm and blepharospasm.  Hemifacial spasm means half of the face, have spastic, tic like movements, and you can place neuromodulator there to relax the muscles.

What she noticed was that the wrinkling of the glabellar area was less when she would treat up to that level.  She was married, or she is married even still now, to , Dr. Alistair Caruthers, who's a cosmetic dermatologist. And she came back and said, you know, I know you're doing all these different things for, for the wrinkles, but oh my goodness, we're onto something here with Botox.

And she went back to Allergan and proposed this idea and look at where it is now for Allergan.. 

Kane: So that was just a remarkable coincidence that she just happens to be married to somebody in the cosmetic dermatology space. 

Remarkable coincidence. But also remarkable for her to have such keen observation skills and to say that there's an idea here, I love that. And now it's a multi billion dollar product for Allergan, so it, it really changed the whole landscape of Allergan.  I'm gonna start with Botox because that was the first neuromodulator and Botox, has complexing proteins around it, which complexing proteins are thought to stabilize the core molecule (debatable). 

The core molecule Kane, is the same, whether it's Botox, Dysport, Xeomin  or Jeuveau. That core component is the same, the proteins that are surrounding around each brand are different and  Xeomin, does not have any proteins around it, so it is considered the "naked" botulinum toxin. 

Kane: So that's where you'll see some subtle differences between the products. But overall, they still have that same core. 

Dr. Saluja: Correct, though there are some subtle differences. So Botox takes about one to two weeks to kick in. I tell patients 95% is kicked in at one week. A hundred percent is kicked in in two weeks, and all the toxins take about 20 to 90 minutes to absorb into the muscle. So while we say, don't put any pressure on, don't exercise for three hours, heavy exercise, the reality is it's probably a little overkill. After two hours you probably could, we say don't have massages until the next day, again, that's probably a little overkill too, because after about 90 minutes, it's in the muscle.

When I, when we do Botox injections patients might look like they have a little bit of a mosquito bite for about 15 minutes. They possibly could bruise. There's lots of, lots of vessels that crisscross over our face, so there could be a bruise,  certainly around the eyes potentially, or, or the forehead area. But for the most part, it's not that uncomfortable. There's just a lot of little tiny injections. 

And we use cold air in our practice that kind of helps minimize some of that as well. And there's multiple areas where it could be placed. 

So, but some of the classic areas are between the brows and typically anywhere between 20 to 30 units are placed there.

 Men typically need higher dosages, the forehead and on label for Allergan, they recommend 20 units between their brows, 20 units to the forehead and 24 units around the eye. So that's 64 units. Well, we don't do that many. I would say the average is anywhere between,40- 60 units for females and higher (up to 90 units) for males. 
 
Kane: So even though Botox or Allergan is recommending a total of 64 units, the the art of knowing where and how much to inject is, is really, that's the injector of, of determining that. 

Dr. Saluja: Correct. And you know, patients will know that when they come into the office, I look at them, I look at them head on, and I look to see is there a brow lower, is there any lid laxity?
Because as we get older, we get excess skin around our eyes and a lower brow position becomes apparent and we use our forehead muscle considerably to lift our brows.  So, Put too much Botox there on someone with lid laxity and lower brows, boy, they're gonna feel it and they're gonna say, oh my gosh, I can't, I can't open my eyes to put my makeup on. So you have to really look to see what you're trying to achieve. And sometimes wrinkle reduction is not what you want. If it means that the eyes are gonna be,  more closed. 

Kane:  So you said wrinkle reduction. Talk a little bit more about what type of wrinkle, because I know sometimes the expectations are that it's gonna smooth out all the wrinkles and that's not necessarily the case. 

Dr. Saluja: Right. So it helps with dynamic wrinkles. That means wrinkles that are created in motion. So when we,  furrow our brows, we create those 11 lines. It can help with that. But sometimes patients will have static lines, which means those lines are present even when they're at rest. And when you take your fingers and you try to stretch, stretch the skin out, they still have those lines.

Those will not be dissipated by Botox. So those lines, those static lines that's where lasers et cetera can be done. Sometimes I run smooth threads there as well.. So again, it's the dynamic lines. Now there are multiple areas. Again, we talked about around the eyes, the forehead between the brows. We do the areas on the chin, for the "pebbly chin". I do around the lips. That's the classic lip flip. We do areas around the mouth. So when we pull our mouth down, if our mouth looks like it's frowning. , you can inject into a little muscle there, which pops that mouth up. We do platysmal bands. There's a Nefertiti lift. We, so there's multiple, multiple, areas to inject Botox and get a nice benefit.

Kane: Okay, so we talked a little bit about Botox. Let's briefly cover the other three as well. 

Dr. Saluja: Sure. So Dysport is another one. Dysport came out second, and when you talk about Dysport, Dysport kicks in. It's my, my "quick tox", so it kicks in in two to four days. So if someone has an event, we would certainly use Dysport over Botox because it's a little quicker if they have an event that weekend and they're sitting in my chair on on a Wednesday.

But Dysport also has a little greater diffusion and what I mean by that is that it spreads a little bit more. So if there's a large muscle, again, that forehead muscle where I don't want to put a lot of units, but I want some more spread, Dysport might be the one I select.

And sometimes I notice that you may use, some Dysport and some Botox on the same patient, why is that? 

Correct. Because Botox has less diffusion. So for smaller muscles, or if I'm getting a little closer to the under part of the eye, I might select Botox. But for the glabella and for the forehead, I might select Dysport. So we customize the treatment based on the muscle size and what we're trying to achieve.

Kane: I'm a visual learner, so a visual aid helps me. So I know you've talked about the quarter,  nickel, dime. What? What do you mean by that?

Dr. Saluja: So that's in regards to diffusion. I'll tell you about that at the very end. So the next toxin is Xeomin and Xeomin is the naked botulinum  neuromodulator, meaning it doesn't have those proteins that are around the core molecule. And it's thought that maybe the proteins are also kind of turning on our immune system that might cause some resistance, some greater resistance, because we do, we can get, and we do see resistance over time with the neuromodulators, not as much with Xeomin, but with the other ones we can see that.

True resistance, true antibodies that are formed is very, very rare though. And usually we see that. I did have a patient that came in where she did not respond to anything no matter what the dosage was, and we came to find out that she, that she had been receiving 300 units of Botox for her migraines. So higher dosages can lead to resistance over time.

Kane: Wow. Okay. 

Yeah. 300 units that would, that would accelerate it probably.

Dr. Saluja: Right.  And that's a classic dosage for migraines. And so, so Xeomin is the naked botulinum. And again, it's not a one to one ratio. Just like Dysport, you need three units of Dysport to equal one unit of Botox. So we call that a Botox equivalent unit. Xeomin is about 1.3 to 1.5, to equal one unit of, of Botox. And then finally there's Jeuveau which is pretty consistent, one to one ratio. It's very, very similar to Botox. It kicks in in one to two weeks. It does have the complexing proteins around it to stabilize the molecule. this is where the diffusion part comes in.

Kane: So what are the differences? 

Dr. Saluja: Jeuveau diffuses the least amount. So if you've got a little teeny area of a muscle you would use Jeuveau or Botox. So upper lip flip could be Botox or Jeuveau.  Jeuveau diffuses the least amount, kind of like the size of a dime. And I'm just giving this out as an analogy.

Botox diffuses a little bit more than Jeuveau so it's kind of the size of a nickel and Dysport  diffuses the most. So it's kind of the size of a quarter. So if I'm in a very small muscle, again, I won't select Dysport I'll select the others. But if I want greater spread, I might select Dysport so, so that's why it's kind of nice to customize with that.

But, and then after the   injection again, we say, no heavy exercise for three hours, no yoga until the next morning. And there's one study that was done that shows that maybe a little bit of zinc can increase the duration of Botox. The study was in zinc naive patients and it was given two days before and up to five days after.

I just tell patients, you know, eat some almonds, eat some seafood, maybe, um, even your multivitamin, which. has 6-11 mg.

Kane:  But so generally speaking, you have the four toxins that are on the market. They all work, they all have the same core molecule. There may be subtle differences in terms of how quickly they start um, but they all last about the same amount of time.  
Dr. Saluja: Absolutely. a lot of these toxins have rewards programs and so sometimes I'll say, okay, if there's a rewards program for one, let's use that toxin today.  But remember, Alle (Botox) will only give points if you do 20 units or more.

Sometimes patients do have preferences. I mean, I do get some patients that come in that will say, Botox no longer works for me, and will try Dysport and they get a great response or vice versa. So, you know, there are  some subtle differences, but otherwise, yes, I, I like them all. 

Kane: Okay, so, is there anything else that we need to cover about the four that we already know?  Because I know we're excited to talk about the new one. 

Dr. Saluja: That's the primary thing for the fours. I like them all. I love them all. Whatever has a coupon I'm happy with. But whatever toxin that patients like, let's stick with that. So lots of times patients don't like to change their toxin, so that's why we offer them.

But they may decide to change their toxin, whe when Daxxify comes out or not, but, so let's talk about Daxxify and Kane. Can you, so right now Daxxify is in a bit of a soft launch, and can you kind of go over what that means?

Well, right now, and I'm not sure if I term it as a soft launch, but it's, they are launching it in a very, Uh, controlled way.

There's limited inventory that they're gonna put out in the market because right now, everything  known about Daxxify has been done in a, in a controlled setting. So all their data, clinical data, it's compelling, but it was in a controlled environment. Um, it's not in the real world.

And then everything they know in terms of how the market is gonna perceive it has just been done on market research. So once it launches, we're gonna learn a lot. They're gonna learn. In terms of clinically, how does it react in the real world? And then also how does the market react to it in terms of their embracing of it and, and how best to market it.

So there's a lot to still learn and that's why they're going slow. 

So this is what we do know about it.

So the studies are showing with Daxxify that 50% of patients had no, or minimal movement of their frown line. So right now it is FDA approved for the , glabellar area, and their dosage that they have approval for is 40 units, and it takes. It's basically two units of Daxxify equals one of botox, 

so that's equivalent to 20 unitsis their 40 units. And so when they say 50% of patients have no or minimal movement, that means 50% of patients do. So that's important to  know as well, but it's still compelling data because a lot of the data for the previous ones are more at the 12 week mark. So this is definitely compelling data.

Now, three to 5% of the patients actually had um, minimal movement at nine months. So a very, very small percentage actually extended to nine months, but w hat everyone knows. Patients that are, my patients know that I am conservative. 

I like to kind of wait. I know last year there was compelling data about an injectable that came out for cellulite and in the real world, you know, the, that degree of, of that compelling nature was maybe not quite there.

And so to the point where I actually stopped utilizing that particular injectable. So I do want to see how Daxxify performs. I also wanna see the cost profile.   Does this represent a double dose, in which case the current toxins on market can also give longer lasting results with increased dosage (2-4x the dosage), but then we run into increased immune response.   

Dr. SalujaYeah. At So I am certainly excited. We will kind of stay on top of the literature  certainly if it's something that looks good, we will have it for you all, 
but that's why we're kind of excited that it can possibly disrupt the market. If you can get six months instead of three months, that's, that's pretty exciting. But proof is in the pudding and you know, we're taking the approach of let's, let's wait, let's learn more and make sure that the value is there, which, which we think it might be 

And we also want to see is there an allergenicity rate? The studies show that there wasn't, uh, thus far, but we'll certainly be looking at that as well. 

Okay, Thank you so much everyone. I'm sorry we did not do a, um, phrase that saves today. We'll do it the next time and we'll also, we'll have a surprise for what we do the next time. 

Okay. great. Thank you all for listening. 

Thank you Bye-Bye. 

Bye.