Botulinum toxin - Hamilton Fraser

We can provide cover for botulinum toxin within your medical malpractice insurance policy.

If you are looking for insurance to cover botulinum toxin, please contact the team on 0800 634 3881 or email

Who does Hamilton Fraser cover for botulinum toxin treatment?

Hamilton Fraser covers doctors, nurses, dentists, dental therapists, pharmacists, paramedics, operating department practitioners and physiotherapists.

Practitioners must undertake both theoretical and face-to face practical training and they must be presented with a certificate of completion. Regardless as to whether it is CPD approved, the training must be taught by a registered medial professional to meet the eligibility criteria for botulinum toxin insurance with Hamilton Fraser. Read more in our article on aesthetic training and CPD .

Other requirements include:

● Face to face consultations with relevant signed consent from the patient

● Photographs or digital images of the patient capturing the treatment area immediately prior and following treatment, retained by the practitioner for at least three years after the date of treatment

What is botulinum toxin?

Botulinum toxin, also known by the brand name ‘Botox’, is a popular non-surgical, injectable treatment that reduces lines and wrinkles. It is one of the most popular aesthetic treatments across the globe, with a market size of 3.41 billion, expected to increase to 5.68 billion by 2028. Botox is a neuromodulator (a form of botulinum toxin type A) that is injected into targeted treatment areas using an ultra-fine needle to temporarily prevent a muscle from moving.

Other type A botulinum toxin brands include: Vistabel, Dysport , Azzalure, Xeomin and Bocouture; and type B toxin Neurobloc. Each is slightly different, particularly when it comes to dosage units, so they are not interchangeable.

How does botulinum toxin work?

The botulinum toxin mechanism of action works by blocking the nerve signals needed for facial muscles to contract. It is the repetitious contraction of facial muscles that causes expression lines and wrinkles. Once injected, botulinum toxin relaxes the muscles and decreases their movement to reduce the appearance of lines or wrinkles in the area. In time, the toxin is broken down and movement returns.

How long does botulinum toxin take to work? It can take two to four days before the weakening of the muscle begins and movement is stalled. Maximum results can be seen ten to fourteen days after treatment.

What is botulinum toxin used to treat?

There are numerous uses of botulinum toxin, including both cosmetic and medical. Cosmetically, it is used to reduce the signs of ageing, including fine lines and wrinkles on the face. Patients typically seek treatment for the eyebrows, forehead, nose, eyes (crows’ feet), chin and jawline, and neck.

Medically, botulinum toxin has been used for decades and is often recommended for the treatment of chronic migraines, excessive sweating (hyperhidrosis), excessive muscle contractions (dystonia), eyelid twitching, spasticity and bruxism amongst other conditions.

How long does botulinum toxin last?

Botulinum toxin injections typically last three to six months. However, this may vary, depending on the:

● Patient’s age

● Patient’s sex

● Patient’s muscle mass

● Injection technique

● Volume of the solution

● Positioning of the injection

● Dilution of the toxin

To maintain the effect, the patient will need regular follow-up injections.

Who can benefit from botulinum toxin?

Botulinum toxin can benefit patients who wish to reduce or prevent signs of ageing, including wrinkles and fine lines. Additionally, injections can benefit patients experiencing medical conditions such as chronic migraines, excessive sweating, muscle spasticity and bruxism. Patients must be over the age of 18 and have a consultation prior to treatment to make sure they are suitable.

Botulinum toxin is not recommended for patients who:

● Have a history of an allergic reaction to botulinum toxin

● Have a localised or systemic infection

● Are pregnant or are breastfeeding

● Have disorders that affect muscle function, such as myasthenia gravis, multiple sclerosis and motor neurone disease

● Take drugs that affect muscle movement or acetylcholine activity, including medications for certain infections, heart disease, glaucoma, Parkinson’s disease, Alzheimer’s disease, bladder muscle dysfunction, among others

● Have blood clotting problems or intake of a blood thinner like aspirin

What are the different types of botulinum toxin?

There are currently two different types of botulinum toxin commercially available in the United Kingdom:

● Type A toxin: Botox (Vistabel), Dysport (Azzalure) and Xeomin (Bocouture)

● Type B toxin: Neurobloc

What happens during a botulinum toxin procedure?

During the procedure, patients do not tend to feel too much discomfort. At the start of the session, the patient’s face and injection site will be cleaned and, depending on the area treated, the practitioner may numb the skin, either by using topical anaesthesia, or ice and vibration anaesthesia, to reduce any pain. A thin needle is then used to inject tiny amounts of botulinum toxin into the patient's skin or muscles, depending on the treatment chosen. The number of injections needed depends on many factors, including the location and size of the treatment area. Following the procedure, patients are advised not to rub or massage the treated area for 24 hours, to prevent the toxin from spreading to a different area. Patients may experience some discomfort, but this is tolerable. The whole treatment should usually take no longer than 10-15 minutes.

What are the side effects of botulinum toxin?

Botox, as well as other brands, is FDA-approved and is proven to be safe to use. However, patients may experience side effects such as redness, pinprick marks, swelling and bruising, but these should subside shortly after the treatment. If a patient notices prolonged bruising, irritation or infection around the area, drooping, or experiences difficulty swallowing, they should call their practitioner straight away for advice and aftercare.

Patients should avoid exercise, alcohol, aspirin and ibuprofen for 24 hours following treatment, and should not rub the treated area as it may lead to the toxin moving.

What is the recovery time for botulinum toxin?

Botulinum toxin injections do not require any recovery time, meaning patients do not have to take any time off work and can resume their usual activities right after treatment. In terms of aftercare, patients are advised to avoid alcohol and exercise for 24 hours. Make-up should also be avoided for 24 hours, as applying it may rub the skin and disperse the toxin. In addition, patients should avoid other skin treatments such as facials and dermal filler for 24 hours, and stay out of the sun for at least four hours. The heat can promote flushing and increase the patient’s blood pressure, which may encourage bruising.

What training is required to administer botulinum toxin?

Health Education England (HEE) states that the minimum requirements to administer botulinum toxin are:

● A Level six qualification to perform basic upper face botulinum toxin procedures only

● A Level seven qualification for ‘comprehensive use’. This means that a practitioner should be able to ‘deal with complex issues, make sound judgements and act autonomously in implanting tasks at a professional level’

A certified botulinum toxin training course will provide practitioners with the qualifications needed to practise botulinum toxin in the UK, and will provide formal proof of competency to deliver cosmetic procedures safely. The HEE guidelines state that the programme must cover:

● Basic principles of aesthetic procedures

● Basic principles of the consultation process

● Modality specific training

Who can administer botulinum toxin?

Qualified medical practitioners such as doctors, dentists, plastic surgeons, general surgeons, dermatologists and nurses can administer botulinum toxin. Beauticians, beauty therapists and other non-medics are not allowed to inject botulinum toxin as it is a Prescription Only Medicine (POM).

What Hamilton Fraser policy conditions should practitioners be aware of?

An increasing number of claims for compensation are being made against clinics and medical practitioners who perform botulinum toxin injections, and the need for frequent treatments can increase the possibility of complications arising. It is the most popular treatment for most aesthetic practitioners therefore comprehensive cover is essential. It is very important that practitioners are aware of and comply with the policy conditions, as we are unlikely to make payment if an incident occurs while policy holders aren’t in compliance.

Policy conditions include the following:

· Consultations must be carried out face to face and the relevant signed consent must be obtained from the patient

· Photographs or digital images must be taken of the client capturing the treatment area of their body immediately prior to treatment and after

· These photographs and digital images must be retained by the practitioner for at least three years after the date of treatment

· There is an increased excess of £500 for treating temporomandibular joint dysfunction (TMJ) / migraines (subject to relevant training)

Botulinum toxin insurance claims: example scenarios

With any injectable treatments, there will always be potential side effects. All known side effects must be explained to the patient in the consultation and a consent form with the risks must be signed by the patient prior to the procedure.

An example of the type of claim we receive could be that a patient has suffered a brow droop following a treatment. Brow droop is a known side effect of botulinum toxin, so as long as it is documented that this was explained to the patient and they signed consent, liability can be denied by the insurers. In this situation, what is important is that there is sufficient evidence in the patient’s file to show that the risks were discussed at the consultation stage.

Another example of a botulinum toxin claim could be that a patient who was given botulinum toxin injections and was happy with the initial treatment, after a while develops eye pain and blurred vision. The patient seeks specialist advice and is advised that their symptoms could be a result of the botulinum toxin spreading. The patient had not been advised that this side effect could happen, as the practitioner did not carry out a thorough consultation. Liability will have to be admitted in this scenario as the patient had not been given information about all known side effects, and as a result the patient was not fully aware of the risks of having the treatment. Any payment (damages) awarded to the patient would depend on the severity and the longevity of the injury. This could vary from a few hundred to tens of thousands of pounds.

Claims top tip: Make sure the consultation is not rushed and note all the conversation down. A copy of the consultation will be needed if a claim was to come in at a later date.