Meso-tox: an effective off-license treatment

Aesthetic consultant Dr Anoob Pakkar-Hull addresses the industry’s concerns about the latest off-license treatment that everyone is talking about.

Most practitioners may have heard of the “meso-tox” treatment – perhaps by its other common names: meso-botox, skin-tox, skin botox. Despite this promising aesthetic treatment gaining popularity with practitioners all over the world, it still seems that there is some confusion and obscurity around the topic.

In this article, I want to help clear our understanding, bust some myths, and provide practical guidance on how to use this off-license treatment effectively and to the highest medical standards.

What is meso-tox? Where can it be used? How is it done? Finally, and importantly, where do we stand from a legal point of view?

WHAT IS IT?

The name meso-tox combines two words: “meso” (Greek for the middle layer of the skin) and “tox” referring to botulinum toxin A (BoNT-A), the popular neurotoxin used in aesthetic procedures for around two decades, commonly known as Botox® (the trade name for botulinum toxin produced by Allergan). Other common brand names include Dysport® (USA)/Azzalure® (UK), Xeomin® (USA)/ Bocouture® (UK), and Jeuveau® (USA)/ Nuceiva® (UK).

When browsing the internet, you can find people defining meso-tox as a combination of BoNT-A and micro-needling or mesotherapy. This can be confusing, even though neither is completely incorrect.

I would clarify this by keeping the definition simple: meso-tox is a treatment where you inject BoNT-A into the dermis (mid-layer of the skin), which can be done using different needling techniques.

Whereas classically BoNT-A is injected into the muscle to stop it from contracting, mesotox targets the dermis. This does not affect the action potential and muscles contract as normal, whereas the action is restricted to the surrounding pores, contracting them and as a result reducing the secretions (sweat) from them. Altogether, this works to tighten and smooth the appearance of the skin, leading to a more rejuvenated look.

Recent studies have also shown that by reducing sebum production, BoNT-A has benefits in treating acne vulgaris. This is another added benefit to the meso-tox treatment.

WHERE CAN IT BE USED?

Well, the treatment can be performed nearly anywhere on the skin. However, it is most used to treat the facial area, specifically the forehead, under the eyes, upper cheeks, and malar area. The neck, décolletage, and back are not as common but are also areas that can be treated.

HOW DO YOU DO IT?

Here is a brief overview of the treatment process.

First, topical anaesthesia. After an initial cleanse, a numbing cream may be applied to the area for approximately 20mins for optimal effect.

When performing meso-tox, there are a few different techniques which can be used:

1. Nappage: This is a simple procedure which uses a syringe and a very short 30-32g needle. Using this technique, you can target very specific areas with microdoses of botulinum toxin injected intradermally. Despite the intricacies, this technique is straightforward. Bruising may occur if small vessels are inadvertently punctured’.

2. Micro-needling: Using a roller, stamp, or pen the practitioner simply applies droplets of toxin to freshly punctured skin. This technique gives you reduced ability to target very specific areas, can be unpredictable and lead to product wastage.

3. Incorporated into a micro-needling device: Here, BoNT-A is combined with HA (hyaluronic acid) and sometimes other agents to create a cocktail which can be injected under the skin directly with the micro-needling device. Despite the initial hype, results are unpredictable when compared to other techniques.

RISKS

When following the right guidelines, mesotox is generally a safe procedure with minimal downtime. In most cases, patients will experience mild redness which should go down within an hour or two.

Despite it being a safe procedure, BoNT-A injections carry an element of risk which should be understood by the practitioner and explicitly explained to the patient.

Different target areas have different risks. The upper face and neck, for example, carry minimal risk with mild transient symptoms, whereas the periocular and perioral areas can cause moderate transient symptoms/ impairment.

In the worst-case scenarios, poor injection technique can lead to organ or nerve damage while inadvertent systemic toxic effects can also be life-threatening. Therefore the “off-license” use of BoNT-A should only be performed by practitioners who are qualified to prescribe the drug.

So, where does the use of meso-tox stand from a legal viewpoint?

LEGAL ASPECTS

When a medicine receives a license for use within the UK, the license specifies the terms for its use. Only three brands of BoNT-A are licensed for cosmetic purposes in the UK – Azzalure®, Bocouture® and Botox®. The terms of the license for these products include specified upper facial areas including glabellar, forehead and/ or crow’s feet, in addition to detailed parameters that must be met.

In general, most meso-tox treatments are off-license. Regardless, the off-label use of botulinum toxin is very common and has exploded in recent years. If BoNT-A was only ever used for its licensed indication, it would never have become the multi-milliondollar industry it is today. Nevertheless, when prescribing a medicine off-label, the practitioner’s responsibility may be greater than when prescribing a licensed medicine within the terms of its licence.

According to the UK government guidelines, the following healthcare professionals can prescribe an offlabel medicine: doctors, dentists, independent nurse and pharmacist prescribers and, in some circumstances, supplementary prescribers (who can be a pharmacist, nurse, midwife, community nurse, optometrist, physiotherapist, radiographer, or chiropodist/podiatrist).

In a bid to bring regulation and safety to the industry, the UK government and independent self-regulating bodies have been increasingly active in creating guidelines and standards for us to follow.

Additionally, practitioners should bear in mind that the UK government has recently confirmed its intention to introduce a licensing regime for nonsurgical cosmetic procedures including BoNT-A and fillers. The licensing scheme will introduce consistent standards that individuals carrying out non-surgical cosmetic procedures will have to meet, as well as hygiene and safety standards for premises.

CONCLUSION

To conclude this article, I’d like to use a Latin phrase: primum non-nocere – ‘first, do no harm’. It reminds me that skin rejuvenation should not come at the cost of causing harm to my patient. Remember the Hippocratic oath to uphold ethical and professional standards.

HOW DOES THIS RELATE TO MESO-TOX?

Recently, the Joint Council for Cosmetic Practitioners (JCCP), released new guidance in line with the General Medical Council (GMC), Cosmetic Practice Standards (CPSA) and British Association of Cosmetic Nurses (BACN), stating they do not endorse or permit the remote prescribing of any prescription medicine when used specifically for non-surgical cosmetic treatments. This further emphasises the critical importance of a diligent approach to the prescription of BoNT-A.

I have achieved great results performing off-label use of botulinum toxin. However, I’m fully aware of the risks if its use is not fully understood. Before offering this treatment to your patients, you must be adequately trained, and I highly recommend following all the available guidelines out there.