BOTME Study: A National e-Delphi Study on the Use of Botulinum Toxin for Aesthetic Treatment of Middle Easterners

The demand for botulinum toxin A (BTX-A) cosmetic treatments is growing among individuals with skin of color, primarily due to increased cultural acceptance, social media influence, and patient awareness. However, there remains a lack of standardized, evidence-based guidance on the use of BTX-A in these populations.

To develop consensus-based clinical recommendations on aesthetic botulinum toxin injection practices in patients with skin of color.

A modified e-Delphi method was conducted with 10 board-certified dermatologists specializing in cosmetic dermatology. Inclusion criteria required ≥ 5 years of experience and publications, or teaching activity in BTX-A use. Two e-Delphi rounds evaluated 29 evidence-based statements. Consensus was defined as ≥ 70% agreement.

Consensus was achieved on 22 statements. Key recommendations included initiating BTX-A treatments at ages 30-35, dosing 40-60 IU for the upper face, with 16-20 week intervals, using 2 mL of saline reconstitution per 100 IU, and employing 30-gauge insulin syringes. Topical EMLA was collectively agreed upon for pain control. While several technical aspects, such as injection depth and under-eye applications, remained inconclusive, participants decided on key practical precautions, including posttreatment activity restrictions.

These consensus-based recommendations can standardize, make BTX-A injections safe and effective for skin of color patients, supporting more uniform and comparable treatment results.