CATEGORY AUSTRALASIAN DENTIST57 CLINICAL against the active neurotoxin. Neutralising antibodies may reduce a patient’s response to future treatment. For someone who expects treatment over many years, it is reasonable to consider this possibility when reviewing product choice and treatment history. It is equally important to keep the size of the risk in perspective and avoid promising that any formulation prevents it. Immunogenicity – specifically the risk of developing neutralising antibodies (NABs) that progressively diminish or eliminate the therapeutic response – is a clinically meaningful consideration, particularly for patients requiring longterm treatment. Xeomin takes a structural approach to this problem. It is the only commercially available botulinum toxin type A formulated without complexing proteins – the non-toxin accessory proteins (NAPs) present in other preparations. Through a proprietary purification step, these proteins are removed entirely, leaving only the active neurotoxin. Frevert and Dressler (2010, Biologics) demonstrated that the protein load per therapeutic unit is substantially lower for incobotulinumtoxinA than for onabotulinumtoxinA or abobotulinumtoxinA, concluding that this reduced antigenic burden provides a sound basis for lower NAB formation risk. Longterm data across therapeutic indications – including treatment durations of up to nine years – have confirmed that neutralising antibody development is extremely rare with Xeomin (Jost et al., 2015, Drugs). Nuceiva reaches a similar clinical destination by a different route. It does contain accessory proteins, but the SAKURA program's immunogenicity data is compelling. Across SAKURA 1 and SAKURA 2, no participants developed treatmentemergent neutralising antibodies. The SAKURA 3 long-term open-label extension study, which followed patients through repeated treatment cycles, continued to document an absence of NAB formation and no loss of efficacy attributable to secondary immunogenic treatment failure (Gallagher et al., 2019, Aesthet Surg J). Its Australian Product Information reports no cases of seroconversion across 2,231 treatments with the marketed vacuumdried formulation in the cited trials. That is reassuring trial information. For practitioners managing patients over extended periods, this clinical record provides real reassurance – regardless of the mechanistic difference from Xeomin's protein-free approach. In summary, Xeomin addresses immunogenicity by removing the proteins that drive antigenicity; Nuceiva demonstrates through large-scale clinical evidence that its formulation, while containing accessory proteins, does not translate into measurable clinical immunogenicity in practice. Both are strong choices for patients where long-term treatment is anticipated. Handling and practical considerations Day-to-day handling is where Nuceiva's Korean engineering heritage becomes genuinely apparent. The vial uses innovative packaging with a snap-off cap that requires no vial opener – a small but appreciated detail that removes one of the minor friction points from the clinical workflow. If you have ever hunted for a vial opener mid-treatment, you will understand the value of this design choice. Nuceiva's vials are clean, clearly labelled, and designed with a clinical efficiency in mind that reflects Daewoong's positioning as a precision-focused South Korean biotech company. Xeomin's packaging is familiar and reliable, consistent with Merz's established pharmaceutical presentation standards. Both products reconstitute cleanly and behave predictably on injection, with onset times and duration profiles broadly consistent with each other when used at equivalent units. Which should you choose? The honest answer is that both Nuceiva and Xeomin are excellent options, and your choice will often come down to clinical context, patient history, and preference. For patients with a history of prior botulinum toxin exposure and any question mark over immunogenic secondary resistance, Xeomin's proteinfree formulation offers a mechanistically sound argument for switching. For patients starting a long-term treatment relationship where you want a product with outstanding clinical immunogenicity data and the practical convenience of innovative packaging, Nuceiva is a compelling choice. Naumann et al. (2010, J Neural Transm) noted that the clinical factors driving NAB formation risk include cumulative protein exposure and treatment frequency – a framework that supports considering both products thoughtfully rather than defaulting to one on habit alone. Both are available through the Dermal Distinction Academy store at competitive pricing, making it practical to have both in your fridge and select based on patient need. Understanding the differences between these two products – formulation, immunogenicity mechanism, handling, and evidence base – is part of delivering genuinely informed, patient-specific care. And on that front, either toxin gives you an excellent foundation to work from. u Dr Giulia D'Anna is the founder and Head of Faculty at Dermal Distinction Academy, a Key Opinion Leader, and an international lecturer in cosmetic injectables. Nuceiva and Xeomin are available through the Dermal Distinction Academy practitioner store. Visit www.dermaldistinction.com for more information. Carl Burroughs Managing Director 0416 190 000 carl@practicesales.com.au I have worked with Carl Burroughs for many years and throughout that time I have always found him to be professional, insightful, and genuinely committed to achieving the best outcome aligned with my interests. What has always stood out is Carl’s strong ethical approach. At every stage, his advice is guided by integrity, honesty, and experience. Carl brings a unique combination of strategic business understanding and practical experience garnered over decades. His advice is therefore thoughtful, commercially sound, and always delivered in a way that is approachable and easy to understand — always available when needed and consistently willing to assist. Simply, I recommend him to any practice owner seeking experienced and ethical guidance. Dr Jamie Galbraith BDS MFDS MOrth DClinDent
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