Here's How Botox Has Evolved Over 20 Years

Botox, more formally known as Botulinum toxin type A, is a treatment that needs no formal introduction. However, we can easily talk about the highly sought-after procedure for hours (it's that fascinating). Over the last 20 years, Botox has become the most popular cosmetic treatment nationwide. In 2020 alone, more than four million people received Botox injections to temporarily treat areas including frown lines, forehead lines, and crow's feet.

Medically, Botox has cemented its status as a game-changer in the minimally invasive category. The treatment requires little-to-no downtime and delivers full results within 30 days. Culturally, it has grown into a societal phenomenon, with celebrities, influencers, and editors openly singing its praises. The continued consumer affinity for Botox over the last two decades is a subject worth analyzing in-depth. So, we tapped three of the industry's leading skincare experts to break down the treatment's 20-year history. Ahead, Botox pioneer Dr. Jean Carruthers and board-certified dermatologists Dr. Michelle Henry and Dr. Marina Peredo unpack the origins of Botox, its position in the beauty industry, and how it has evolved.

The Beginning of Botox 

The origins of Botulinum toxin type A's medical applications date back to the 1970s. At the time, Dr. Alan Scott specifically used it to treat patients with strabismus (crossed eyes). Scott began to brand the neurotoxin as “Oculinum” through his company Oculinum, Inc. In 1989, the FDA officially approved it to treat strabismus, blepharospasm (uncontrolled eyelid twitching), and hemifacial spasm (involuntary facial twitching).

Around that same time, Dr. Carruthers began working with Dr. Scott and noticed Oculinum's effect outside of ophthalmology. "In 1987, the blepharospasm patient I’d been treating with the product came to me noticing a difference in the wrinkles around the untreated eye," Dr. Carruthers says. "She said, 'You didn't treat me here,' and I apologized to her. I said, 'I'm so sorry, I didn't think you were spasming there.' And she said, 'I'm not spasming there, but every time you treat me in my spasming eye, I like the way it looks.' This was the first time I had thought about the effect on wrinkles."

Dr. Carruthers, her husband (cosmetic dermatologist Dr. Alastair Carruthers), and colleagues began spearheading clinical trials to examine this observation further. The Carruthers' 1992 research found that 16 of 17 patients saw their glabellar frown lines improve when treated with Botox.

By this time, pharmaceutical company Allergan had acquired Oculinum and rebranded it as Botox. Following continued studies of its wrinkle-smoothing benefits, the treatment received FDA approval for cosmetic use under the name Botox Cosmetic on April 15, 2002.

The Rise of Botox Cosmetic

Once Botox became FDA-approved, it became the topic of discussion in the medical community. "The approval in April 2002 was remarkable because suddenly you could talk about it," Dr. Carruthers says. "We were invited all over the world to lecture. Soon, people were starting to do their own studies and publish their own work. So really, it created a language [that allowed] doctors in every country to understand what everyone else was talking about and expand their research."

Botox also began creating a buzz in affluent circles in the early aughts. At the time, Dr. Peredo says, "Botox was mainly accessible to celebrities or wealthier people." While she notes many preferred to be discrete about their use of Botox in the 2000s, some were vocal about its benefits. Personalities like Sharon Osbourne admitted to having Botox on her talk show in 2003 (and got the procedure done in front of a live studio audience). The Real Housewives of Orange County star Vicki Gunvalson is seen getting injections in the show's opening credits in 2006. In Joan Rivers' 2008 book, Men Are Stupid...And They Like Big Boobs: A Woman's Guide to Beauty Through Plastic Surgery, she dubbed Botox a “miracle in a needle.”

Allergan's sales reflected this rapidly growing desire for the treatment. According to the company's Securities and Exchange Report from 2003, they made $439.7 million in net sales from Botox in 2002. In 2003, sales rose to $563.9 million. In total, over 100 million vials have been sold in the United States since 2002. 

The Evolution of Botox Cosmetic

With numbers this massive, it's clear Botox greatly appeals to an audience beyond the rich and famous. "Now, Botox is a household name," Dr. Peredo notes. "More younger patients and millennials are doing it and talking about it." Enter: the rise of preventative botox.

The American Academy of Facial Plastic and Reconstructive Surgery's 2018 survey found Botox Cosmetic treatments among 22 to 37-year-olds rose by 22% since 2013. Allergan has tapped notable figures like 35-year-old reality television star and Love Wellness founder Lo Bosworth as an ambassador to continue to connect with this group. 

Dr. Carruthers has noticed the sweeping generational shift in her practice as well. "I was predominately treating women and men in the Baby Boomer generation, and now, Millennials are the dominant proportion of the workforce," she says. "Millennials don’t see any stigma in receiving Botox Cosmetic."

Practitioners have also seen more diversity in the ethnic groups seeking treatment. "It’s not only Caucasian women around 40+," Dr. Henry says. "People are admitting the mentalities of 'Black don’t crack' and 'Asians don’t raisin' are dated. Even if you don’t 'crack,' you’re allowed to take care of yourself, which starts with minor procedures."

As the layered stigmas around cosmetic procedures have begun to lessen, consumers' aesthetic desires have evolved in tandem. Dr. Henry and Dr. Peredo both agree people are taking a "less is more" approach these days.

"There was a wave when people were overdoing fillers and Botox to achieve a 'frozen' look," Dr. Peredo explains. "Lately, the trend is a more natural look with fillers and Botox where people can still be expressive and look their best but not overdone."

Beyond the demographic and aesthetic changes in the industry, there have been advancements in the ways Botox can be used. It has received FDA approval for several additional cosmetic and therapeutic uses since 2002.

On the cosmetic front, Dr. Peredo says: "Now, Botox can be used to treat the masseter muscle in the temporomandibular joint (TMJ), which can reshape the face and make it more feminine. It can treat a gummy smile, lip lines, under the nose (to lift the tip of the nose), and on the lash line (to even out the eyes if one is smaller than the other). It can be used on the jawline and neck." 

For therapeutic purposes, Dr. Peredo notes people can get Botox injections to treat excessive sweating, migraines, and overactive bladders. 

Final Takeaways

As Botox Cosmetic celebrates its 20th anniversary, there are so many elements of the groundbreaking treatment to reflect on. From a historical standpoint, it is the first and only FDA-approved product for treating frown lines, forehead lines, and crow's feet in adults. 

On a more personal level, Botox Cosmetic treatments have become a confidence-boosting tool for many. "My Gen-X and Millennial patients don’t believe Botox treatments are a vanity thing—it’s just something they do for themselves," Dr. Carruthers says. "They’re empowered."

The practicality and personal benefits of Botox are two reasons why the global botulinum toxin market is projected to grow from $3.41 billion in 2021 to $5.68 billion by 2028. Considering these numbers, it's safe to say Botox will continue its reign as a superstar cosmetic treatment. Here's to another 20 years of Botox.