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What are the differences between Xeomin, Botox, Dysport, and Jeuveau? (Updated 2022)

botox xeomin dysport jeuveau

SUMMARY:
Based on research data, all four FDA-approved neurotoxins are effective and well-tolerated.
Botox, Jeuveau, and Xeomin are equivalent in units. Dysport is dosed in higher units.
Xeomin has a purification manufacturing process and does not need refrigeration.
Xeomin has a lower price for medical practices from the manufacturer.

In 2021, FDA has approved 4 neurotoxins for use to reduce the wrinkles in the frown lines between the eyes.  Let’s go over each of the botulinum toxins and find the difference between them.  Although our focus is on the Xeomin Challenge, I will give you an unbiased opinion on the 4 neurotoxins.  Then, you’ll understand why we decided on Xeomin.

(Disclaimer: This website and blog are about the Xeomin Challenge and there is a financial relationship to Xeomin.)

What are the different botulinum toxins?

Botox = ONAbotulinumtoxin A
Dysport = ABObotulinumtoxin A
Xeomin = INCObotulinumtoxin A
Jeuveau = PRAbotulinumtoxin A

Botulinumtoxin A (“BoNT-A”) is a purified strain of botulinum toxin.

The different prefixes “Ona,” “Abo”, “Inco,” and “Pra,” indicate the differences in the biologic properties of each botulinum toxin. 

Which one is better?

This is a question that I get asked ALL OF THE TIME.  For the sake of impartiality, let me show you a chart with many of the research publications that compare one toxin vs another

TitleConclusionWinner
Botox, Dysport, Xeomin
A mixed treatment comparison to compare the efficacy and safety of botulinum toxin treatments for cervical dystoniaBased on this MTC analysis, there is no significant efficacy difference between Dysport, Botox, Xeomin and Myobloc at week four post injection.None
Conversion Ratio between Botox®, Dysport®, and Xeomin® in Clinical PracticeONA and INCO have comparable efficacies with a 1:1 conversion ratio and have demonstrated therapeutic equivalence in different indications including cervical dystonia and blepharospasm. An ONA to ABO conversion ratio ≤1:3 should be considered the most appropriate.None
A Quantitative Analysis of OnabotulinumtoxinA, AbobotulinumtoxinA, and IncobotulinumtoxinA: A Randomized, Double-Blind, Prospective Clinical Trial of Comparative Dynamic Strain ReductionUsing digital image correlation, the tested neuromodulators do not have equivalent strain reduction in the glabella at the doses used. These results confirm assertions of noninterchangeability.None
Onset and duration of effect of incobotulinumtoxinA, onabotulinumtoxinA, and abobotulinumtoxinA in the treatment of glabellar frown lines: a randomized, double-blind studyIncobotulinumtoxinA demonstrated a more rapid onset and a longer duration of treatment effect than onabotulinumtoxinA (1:1 dose ratio) and abobotulinumtoxinA (1:3 dose ratio).Xeomin
Botox VS. Dyspot
Prospective Randomized Comparison of OnabotulinumtoxinA (Botox) and AbobotulinumtoxinA (Dysport) in the Treatment of Forehead, Glabellar, and Periorbital WrinklesResults showed no statistically significant differences between the two agents. Both agents yielded measurable improvements on wrinkles of the upper face at 150 days.None
Efficacy of Onabotulinum Toxin A (Botox) versus Abobotulinum Toxin A (Dysport) Using a Conversion Factor (1 : 2.5) in Treatment of Primary Palmar HyperhidrosisThe efficacy and safety of Botox and Dysport injections were similar using a conversion factor of 1 : 2.5. There was a trend towards a more rapid action after Dysport treatment but without significant importance.None
Dysport and Botox at a ratio of 2.5:1 units in cervical dystonia: A double‐blind, randomized studyThe mean change of the Toronto western spasmodic torticollis rating scale score, the proportion of improvement in clinical global impression and patient global impression, and the incidences of adverse events were not significantly different between the two treatments. With regard to safety and efficacy, Dysport was not inferior to Botox in patients with CD at a conversion factor of 2.5:1.None
A Single-blind, Split-face, Randomized, Pilot Study Comparing the Effects of Intradermal and Intramuscular Injection of Two Commercially Available Botulinum Toxin A Formulas to Reduce Signs of Facial AgingThere was no statistically significant difference between onabotulinumtoxinA and abobotulinumtoxinA when injected intradermally or intramuscularly.None
A Randomized Double-Blind Study of the Effect of Botox and Dysport/Reloxin on Forehead Wrinkles and Electromyographic ActivityThe results of the present study show that Dysport/Reloxin has a longer duration of effect on EMG activity and forehead wrinkles than does Botox at a unit dose conversion ratio of 3:1Dysport
Respective potencies of Botox and Dysport: a double blind, randomised, crossover study in cervical dystoniaDysport 1:3 (and Dysport 1:4 to a greater extent) is more efficient than Botox for both impairment and pain in cervical dystonia although with a somewhat higher incidence of minor adverse effects.Dysport
Botox VS. Xeomin
A direct comparison of onabotulinumtoxina (Botox) and IncobotulinumtoxinA (Xeomin) in the treatment of benign essential blepharospasm: a split-face techniqueNo difference between Xeomin and Botox was detected in either subjective or objective measures for the treatment of BEB.None
Comparison of preferences between onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin) in the treatment of benign essential blepharospasmThis study demonstrates that patients who prefer incobotulinumtoxinA over onabotulinumtoxinA had a statistically significant shorter treatment interval. In addition, those who preferred incobotulinumtoxinA thought it was more effective, whereas those patients who preferred onabotulinumtoxinA thought it had a longer duration.None
Xeomin® vs. Botox® A Side-by-Side Comparison in the Same PatientsXeomin® and Botox® are equal unit for unit as might be expected by their common 150 kDa active neurotoxin.None
Comparing Botox® and Xeomin® for axillar hyperhidrosisSide-to-side differences of the therapeutic effect (onset latency, extent, duration) were neither detectable by the patient nor by the physician.None
Measuring the potency labelling of onabotulinumtoxinA (Botox(®)) and incobotulinumtoxinA (Xeomin (®)) in an LD50 assayAlthough the existence of a conversion ratio has been questioned recently, our experimental data are in line with previous clinical experience showing that Botox(®) and Xeomin(®) can be compared using a 1:1 conversion ratio.None
Routine use of Xeomin in patients previously treated with Botox: long term resultsThere were no diffusion differences between Botox and Xeomin. Using a conversion ratio of 1:1 Xeomin and Botox can easily be exchanged in a continued treatment.None
Noninferiority of IncobotulinumtoxinA, Free from Complexing Proteins, Compared with Another Botulinum Toxin Type A in the Treatment of Glabellar Frown LinesAnalysis of the data confirmed the noninferiority of incobotulinumtoxinA.None
Double-blind, randomised, parallel group pilot study comparing two botulinum toxin type A products for the treatment of blepharospasmNo significant differences between products were noted in PGA and adverse events at the doses used in this study.None
A Randomized, Double-Blind Trial to Investigate the Equivalence of IncobotulinumtoxinA and OnabotulinumtoxinA for Glabellar Frown LinesEquivalence was demonstrated at the primary endpoint between incobotulinumtoxinA and onabotulinumtoxinA in the treatment of GFL at the 20 U dose at 1 month. Similar efficacy and tolerability profiles were observed through 4 months after treatment.None
A prospective rater- and subject-blinded study comparing the efficacy of incobotulinumtoxinA and onabotulinumtoxinA to treat crow’s feet: a clinical crossover evaluationIncobotulinumtoxinA and onabotulinumtoxinA (1:1 dose conversion ratio) were well tolerated, showing comparable efficacy and duration of treatment effect for crow’s feet.None
Xeomin VS. Dysport
A Prospective, Neurophysiologic Comparative Study to Assess the Efficacy and Duration of Effect of IncobotulinumtoxinA and AbobotulinumtoxinA in the Treatment of Crow’s FeetIn conclusion, for treatment of crow’s feet, incobotulinumtoxinA and abobotulinumtoxinA (1:3 dose) demonstrated comparable efficacy in terms of magnitude and longevity of effect. Both products demonstrated a high responder rate, with the response being maintained for 6 months in the majority.None
Botox VS. Jeuveau
A Multicenter, Randomized, Double-Blind, Placebo-Controlled, Single-Dose, Phase III, Non-Inferiority Study Comparing PrabotulinumtoxinA and OnabotulinumtoxinA for the Treatment of Moderate to Severe Glabellar Lines in Adult PatientsA single treatment of 20 U prabotulinumtoxinA was safe and effective and noninferior to 20 U onabotulinumtoxinA for the treatment of moderate to severe glabellar lines.None

There are a few studies that state that Dysport at a higher dilution rate (3:1) had better outcomes than Botox.  There is one study that states that Xeomin had a better outcome than Botox.  

Our best conclusion based on the data is that all four are effective and well-tolerated.  A much larger double-blind clinical study needs to be performed before anyone botulinum toxin company can claim superiority. Anecdotally, we have not seen anyone botulinum toxin perform better than the others to smooth fine lines and wrinkles.  They are not interchangeable, but they have similar efficacy and safety.  

What is the unit equivalence?

Another common question is: If I get 20 units of Botox on my frown line, then how much of the other neurotoxins should I get?

Based on the package insert, here is the equivalent amount:
Botox 20 units
Dysport 50 units
Xeomin 20 units
Jeuveau 20 units

However, one research article suggests that the following should be the optimal equivalent amount:
Botox 20 units
Dysport 40 – 60 units
Xeomin 20 units

Is one purer than another?

Xeomin is the only currently FDA-approved botulinum toxin that uses the XTRACT Technology that removes unnecessary proteins.  Xeomin contains only the core neurotoxin protein without other accessory proteins.  In clinical trials, none of the 2650 patients developed secondary treatment resistance due to neutralizing antibodies.  What does this mean?  Well, a very small number of patients can build up neutralizing antibodies against botulinum toxin and accessory proteins.  This can cause the patient to require a higher dose.  In rare cases, the patient becomes immune to the botulinum toxin completely.  So, in theory, Xeomin may be less immunogenic than the other botulinum toxins.

Are there different handling requirements?

Xeomin is the only currently FDA-approved botulinum toxin that does not require refrigeration prior to reconstitution.

Conclusion

All four botulinum toxins are generally accepted to have equal efficiency and safety.  We decided to participate in the Xeomin Challenge, because Xeomin has an additional layer of purity, and is easier to handle due to the lack of refrigeration requirements.  Finally, the Xeomin Challenge offer of $99 for 20 units provides patients a great opportunity to try a different botulinum toxin.

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