The CDC reported that three individuals were hospitalized with botulism-type symptoms in May and June following self-injection of botulinum toxin they purchased online for cosmetic use.

The case descriptions, published on November 27 in the Morbidity and Mortality Weekly Report (MMWR), are the latest examples of severe reactions to unapproved botulinum toxin either purchased online or injected by unlicensed or nonmedical professionals.

Two Louisiana residents were hospitalized in September after experiencing botulism-like symptoms within days of injections. The Louisiana Department of Public Health said in its warning that one person received injections of an unlicensed product bought online. The other received injections from an individual with unknown licensure in a nonmedical setting.

In June, the Massachusetts Department of Public Health warned the public that at least 10 individuals who had received botulinum toxin injections at a spa in Milton had contracted botulism. Just weeks later, authorities in Multnomah County, Oregon reported that an individual who received a botulinum toxin injection for cosmetic purposes from an unlicensed person in a nonclinical setting had suspected botulism.

This follows a 2024 CDC report that 19 people from nine states experienced serious reactions after receiving injections of counterfeit botulinum toxin or injections from unlicensed or untrained individuals or in nonhealthcare settings.

In the newest MMWR report, three women — ages 29, 50, and 59, from New York, Texas, and Wisconsin — bought botulinum toxin from Korea and China. Each self-injected the products.

The first individual injected 11 units into her eyebrows, forehead, and lips. Four days later she developed double vision, dysphagia, dysphonia, and drooping of one eyelid (ptosis). She was hospitalized for 3 days. The second woman injected about 200 units into the platysmal bands of her neck. Within 2 days, she developed bilateral upper extremity weakness, dysarthria, dysphagia, and shortness of breath. She spent 6 days in the hospital and required invasive mechanical ventilation.

The third woman injected about 200 units into her cheeks, eyebrows, forehead, masseters, platysmal bands, and trapezius. She developed symptoms 3 days later and was hospitalized for 4 days. After discharge, she continued to have dysarthria, neck weakness, and ptosis.

All received botulism antitoxin treatment, per CDC clinical guidelines. But the report said it was not clear how beneficial the treatment was because there was no detectable botulinum toxin circulating at the time of administration.

The CDC authors warned that botulinum toxin bought online “might be misbranded, mislabeled or unlabeled, adulterated, counterfeit, contaminated, improperly stored or transported, ineffective, or unsafe.”

People seeking the injections should only receive them from a provider authorized to purchase and administer botulinum toxin, said the report. The report also advises healthcare providers to counsel people interested in botulinum toxin “about risks associated with improper administration and encourage them to seek injections only from licensed, trained medical professionals operating in accordance with jurisdictional requirements and using FDA-approved” botulinum toxin products.

“Botulinum toxin injection is a medical procedure,” said Lawrence Green, MD, clinical professor of dermatology at George Washington University School of Medicine, Washington, DC. “Botulinum toxin is a medical product, and it’s been FDA-vetted,” he added.

If an individual buys a product that has not gone through the FDA approval process, “you have no idea what you’re getting,” Green told Medscape Medical News.

Moreover, self-injecting is ill-advised, he said. “You can’t stick a needle in yourself looking in the mirror and expect to be accurate.”

Internet Provides Sellers and Instructions

The CDC report said that one of the women went online to “research injection techniques for specific anatomic sites.”

It is not difficult to find those guides. Medscape Medical News found one Reddit group that provided links to YouTube videos, textbooks, and research papers that offered detailed instructions on injection techniques — usually aimed at clinicians, not the lay public.

It is also relatively easy to buy botulinum toxin online. An internet search brings up dozens of possibilities. In the CDC report, one woman bought the product directly from a Korean retailer. Another communicated with a Chinese vendor via WhatsApp, and the third found a Chinese seller on TikTok who then used WhatsApp to communicate.

Green said he continues to try to counter misinformation on social media, including a new post about the MMWR report and why it’s important to see a board-certified dermatologist or a physician who is experienced in injecting botulinum toxin.

Users might think that botulism or other adverse events are uncommon, he said.

“But when you play Russian roulette, someone’s going to lose out,” said Green. “Why do that to yourself? You want the safety first.”

Healthcare providers can call the CDC’s clinical botulism service 24 hours a day for information on diagnosing botulism and using botulism antitoxin at: 770-488-7100. Adverse effects from botulinum toxin products, as well as possible counterfeit products, can be reported to the FDA’s Safety Information and Adverse Event Reporting Program.

Green reported no conflicts relative to botulinum toxin.

Alicia Ault is a St Petersburg, Florida-based freelance journalist whose work has appeared in many health and science publications, including Smithsonian.com. You can find her on X @aliciaault and on Bluesky @aliciaault.bsky.social.