Botox: What is it, how does it work, what are the risks?

The idea that anti-wrinkle injections might become as routine for women in their 30s as getting their hair cut or nails manicured was still unfathomable to most viewers. 

Two decades on, Botox is no longer the preserve of wealthy Manhattan PR executives.

An explosion in the availability and affordability of the treatment has made it the UK's most popular non-surgical cosmetic treatment. 

So where did it come from, how does it work - and is it safe? 

The concept of getting 'Botox on your lunchbreak' was popularised by television shows such as Sex and the City

What is Botox? 

Botox is the brand name for a drug made from the chemical, Botulinum neurotoxin. 

Botulinum toxin is a highly potent neurotoxic protein produced by the bacterium Clostridium botulinum.

This is the same toxin which causes botulism, a life-threatening type of food poisoning. 

When injected into the skin, Botox works by blocking nerve endings from absorbing molecules they need to function properly.

This temporarily paralyses the muscles, which can help to smooth wrinkles and reduce the appearance of forehead lines, crow's feet, and frown lines. 

While Botox is the best known form of the drug, two other brands - Azzalure and Bocouture - are also licensed for cosmetic use in the UK.

How was it discovered? 

As a cause of food poisoning, Botulinum toxin was first discovered in 1897 after a group of Belgian musicians fell sick when eating the same smoked ham after performing at a funeral. 

Its potential as a medical treatment came much later. 

In the 1970s, Dr Alan Scott, an ophthalmologist working in San Francisco, California, pioneered a bolulinum-based drug, Oculinum, to treat strabismus - the visual disorder more colloquially known as a 'squint'. 

In 1977, he injected the paralytic into a patient for the first time in trials and, in 1989, Oculinum was granted approval by the FDA - the US drug regulator - as an eye treatment for adults with strabismus and blepharospasm, a form of uncontrollable twitching.

Dr Alan Scott, the 'Father of Botox', died in 2021 (Image: BritishNeurotoxinNetwork)

It would also be used to treat other conditions involving muscle spasms, such as cerebral palsy, and as a remedy for urinary incontinence, migraine, and excess sweating. 

By the time he died aged 89 in December 2021, Dr Scott had lived to see his breakthrough give birth to a revolution in cosmetic medicine. 

After selling Oculinum in 1991 to the drug company, Allergan, it was renamed "Botox" and during the 1990s doctors in aesthetic medicine increasingly began to use it 'off-label' as an anti-ageing therapy. 

In 2002, the drug was given FDA approval as a treatment for frown lines, crow’s feet, and forehead lines.

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Is it safe? 

Most people will not experience any side effects from Botox, as long as it is administered properly by a trained professional. 

In most cases, side effects will be limited to pain, swelling or bruising at the injection site, and a headache or flu-like symptoms for around 24 hours. 

While there have been a string of health scares connected to counterfeit Botox, a study by the FDA found that there were only 36 reports of serious adverse events involving genuine Botox used for cosmetic purposes in the United States during the whole of 2002/3.

Botox is associated with very few side effects if administered properly (Image: Archant)

The risk of adverse events was 33 times higher where Botox had been used therapeutically, to treat conditions such as migraine. 

Adverse events can include infections, vascular occlusion, and - in very rare cases where the medicine spreads to other parts of the body - can result in vision or breathing problems, loss of bladder control, and trouble swallowing. 

Women who are pregnant or breastfeeding are also advised to avoid Botox. 

Who can do Botox? 

In the UK, doctors, dentists, nurses, midwives, and dental nurses can train to carry out and prescribe Botox.

In Scotland, these healthcare professionals must be regulated by Healthcare Improvement Scotland, meaning that they are subject to inspections and regulation fees.

Controversially, there is no legislation anywhere in the UK to stop non-healthcare professionals, such as beauticians, from training to do Botox - although as a prescription drug it should not be available to non-prescribers.

Training to carry out Botox consists of Level 6 and Level 7 qualifications. These require trainees to observe and then perform Botox procedures, under supervision. 

Combined, both courses cost upwards of around £9000, but can be completed over a few days.

Controversially, in the UK there is nothing to stop non-healthcare professionals doing Botox in settings such as hairdressers or beautician salons even though it is a prescription drug (Image: Guilherme Petri on Unsplash)

How popular is Botox? 

Non-surgical cosmetic treatments such as Botox and filler injections account for 90% of all the cosmetic procedures carried out in the UK. 

According to the British Association of Aesthetic Plastic Surgeons (BAAPS), a total of 6,449 Botox procedures were carried out by its members in 2023. 

However, this is only covers Botox treatments carried out by BAAPS doctors.

In 2021, it was estimated that 900,000 Botox procedures had been carried out in Britain, although it is difficult to quantify when a large section of the market remains unregulated. 

How much does Botox cost? 

In the UK, Botox typically costs between £100 to £350 depending on the number of areas being treated, the size of the dose, and the clinic. 

However, consumers are strongly advised to stick to regulated clinics - where the procedure is more expensive - to avoid the risk of complications or exposure to harmful, counterfeit product.