Torsion dystonias and other involuntary movements

Botulinum toxin type A should be used under specialist supervision. Botoxc and Dysportc are licensed for the treatment of focal spasticity (including arm symptoms in conjunction with physiotherapy, dynamic equinus foot deformity caused by spasticity in ambulant paediatric cerebral palsy patients over 2 years of age, hand and wrist disability associated with stroke), blepharospasm,hemifacial spasm, and spasmodic torticollis.

Botoxc is also licensed for severe hyperhidrosis of the axillae.

Vistabelc is licensed for the temporary improvement of moderate to severe wrinkles between the eyebrows.

Xeominc is licensed for the treatment of blepharospasm and spasmodic torticollis.


Indications see notes above; preparations are not interchangeable and should be used under specialist supervision

Cautions history of dysphagia or aspiration; neurological disorders (can lead to increased sensitivity and exaggerated muscle weakness); pregnancy; breast-feeding

Specific cautions for blepharospasm or hemifacial spasm Caution if risk of angle-closure glaucoma; reduced blinking can lead to corneal exposure, persistent epithelial defect and corneal ulceration (especially in those with VIIth nerve disorders)—careful testing of corneal sensation in previously operated eyes, avoidance of injection in lower lid area to avoid ectropion, and vigorous treatment of epithelial defect needed

Contra-indications generalised disorders of muscle activity (e.g. myasthenia gravis)

Side-effects increased electrophysiologic jitter in some distant muscles; misplaced injections may

paralyse nearby muscle groups and excessive doses may paralyse distant muscles; influenza-like symptoms;rarely arrhythmias, myocardial infarction, seizures,hypersensitivity reactions including rash, pruritus and anaphylaxis, antibody formation (substantial deterioration in response), and injection-site reactions;very rarely exaggerated muscle weakness, dysphagia,and aspiration (seek medical attention if swallowing, speech, or respiratory disorders) 

Specific side-effects for blepharospasm or hemifacial spasm Ptosis; keratitis, lagophthalmos, dry eye, irritation,photophobia, lacrimation; facial oedema; less commonly dry mouth, facial weakness (including drooping), dizziness,tiredness, ectropion, entropion, diplopia, visual disturbances,conjunctivitis; rarely eyelid bruising and swelling (minimised by applying gentle pressure at injection site immediately after injection); very rarely angle-closure glaucoma, corneal ulceration


Specific side-effects in paediatric cerebral palsy Drowsiness,paraesthesia, urinary incontinence, myalgia 

Specific side-effects for temporary improvement of moderate to severe wrinkles between the eyebrows Headache; ptosis; less commonly nausea, dry mouth, facial oedema, dizziness, asthenia, anxiety, paraesthesia, visual disturbances, blepharitis, photosensitivity reactions, and dry skin

Specific side-effects in spasmodic torticollis Dysphagia and pooling of saliva (occurs most frequently after injection into sternomastoid muscle), nausea, dry mouth, rhinitis,drowsiness, headache, dizziness, hypertonia, stiffness; less commonly dyspnoea, voice alteration, diplopia, and ptosis

Specific side-effects in axillary hyperhidrosis Non-axillary sweating, hot flushes; less commonly myalgia and joint pain

Specific side-effects in focal upper-limb spasticity associated with stroke Dysphagia; hypertonia; less commonly arthralgia and bursitis



Indications spasmodic torticollis (cervical dystonia)—specialist use only

Cautions history of dysphagia or aspiration; inadvertent injection into a blood vessel; tolerance may occur 

Contra-indications neuromuscular or neuromuscular junctional disorders; pregnancy  and breast-feeding

Side-effects increased electrophysiologic jitter in some distant muscles; dry mouth, dyspepsia, worsening torticollis, neck pain, myasthenia, voice changes, taste disturbances; very rarely exaggerated  muscle weakness, dysphagia, and aspiration (seek medical attention if swallowing, speech, or respiratory disorders)


. By intramuscular injection, initially 5000–10 000 units divided between 2–4 most affected

muscles; adjust dose and frequency according to response; important: not interchangeable with other botulinum toxin preparations








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