Types of Botox in 2026: Every FDA-Approved Neurotoxin, Compared

For decades, the word "Botox" has operated as a generic trademark for neuromodulator injections. When patients visit an aesthetic clinic to smooth out frown lines, forehead creases, or crow's feet, they frequently ask for "Botox" without realizing that their provider may actually be administering one of several chemically distinct, FDA-approved neurotoxin brands.

As of mid-2026, the United States market features six distinct botulinum toxin type-A products approved by the FDA for cosmetic glabellar-line treatment. With new approvals like Letybo in 2024, the pending entry of ready-to-use liquid formulations, and ongoing clinical trials for ultra-fast-onset toxins, the neuromodulator landscape has become increasingly sophisticated.

To help patients and providers navigate their choices, this guide compares every FDA-approved neurotoxin. We examine their BLA application details, formulation differences, onset times, actual clinical durations, unit equivalency guidelines, safety profiles using real FDA adverse-event database volumes, and the state of the 2026 pipeline.

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The 2026 US neurotoxin landscape: The six approved options

All FDA-approved aesthetic neurotoxins are derived from the bacterium Clostridium botulinum and work by blocking the release of acetylcholine at the neuromuscular junction. This temporarily relaxes the target muscle, smoothing the overlying dynamic wrinkles.

However, each brand has a unique Biologics License Application (BLA) path, manufacturer, and structural formulation. The table below compares the six FDA-approved aesthetic type-A neurotoxins, alongside the therapeutic serotype-B option:

FDA-Approved Cosmetic and Therapeutic Neurotoxins (US Market)

Note: BLA numbers, manufacturers, and marketing parameters are sourced from the official Drugs@FDA database.

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Formulation differences: Accessory proteins and peptide stabilizers

While all six aesthetic toxins share the same active 150 kDa core neurotoxin chain, they differ significantly in what surrounds that core chain.

Botox / Jeuveau / Letybo:   [ 150 kDa Active Toxin ] <---> [ Accessory Protein Shield (750 kDa) ]
Xeomin ("Naked"):           [ 150 kDa Active Toxin ]
Daxxify (Peptide):          [ 150 kDa Active Toxin ] <---> [ RTP004 Peptide Stabilizer ]

1. The 900 kDa Complex (Botox, Jeuveau, Letybo)

Traditional formulations like Botox, Jeuveau, and Letybo package the active 150 kDa neurotoxin within a protective coat of non-toxic accessory proteins (hemagglutinins and non-hemagglutinins), creating a large 900 kDa complex.

• In the vial, these accessory proteins stabilize the toxin.
• Once injected, the physiological pH of the tissue causes the accessory proteins to dissociate rapidly from the active 150 kDa core, allowing the active toxin to bind to receptors on the nerve terminal.
• Jeuveau (often marketed as "Newtox") is manufactured using the same 900 kDa complex structure and purification process as Botox.
• Letybo's Clinical Evidence: Approved on February 29, 2024, Letybo's US launch was supported by three identically designed Phase III trials — BLESS I, BLESS II, and BLESS III — which together randomized 1,272 subjects with moderate-to-severe glabellar lines to a 20-unit dose or placebo. On the composite primary endpoint at Week 4 (at least a 2-grade improvement on both the investigator's and the subject's glabellar-line assessment), responder rates were 46.5% in BLESS I, 48.8% in BLESS II, and 64.7% in BLESS III, versus 0–1.9% for placebo. The most common adverse reactions were headache, eyelid ptosis, and brow ptosis — a safety profile comparable to the other type-A toxins — which supports Letybo as a 1:1 dosing alternative to Botox.

2. The "Naked" Toxin (Xeomin)

Xeomin is formulated without any accessory proteins. Through a proprietary purification process, Merz strips away the accessory proteins, leaving only the pure, active 150 kDa core neurotoxin.

• The Clinical Angle: Because it lacks accessory proteins, Xeomin is sometimes referred to as the "naked" toxin. The primary theoretical advantage is that accessory proteins can act as foreign antigens, stimulating the patient's immune system to produce neutralizing antibodies. Over time, these antibodies can cause "treatment resistance," where the injections lose their effectiveness. By removing these proteins, Xeomin minimizes the risk of antibody formation, making it a preferred choice for patients who require high-dose therapeutic treatments or those who have noticed a decrease in their response to other toxins.

3. The Peptide Stabilizer (Daxxify)

Daxxify is the first and only neurotoxin formulated without human serum albumin (a blood-derived protein used as a stabilizer in all other approved toxins). Instead, Revance utilizes a proprietary synthetic, positively charged peptide stabilizer called RTP004.

• The Longevity Mechanism: The RTP004 peptide contains a high density of positive charges. Because the cell membranes of nerve terminals are negatively charged, the positive charges on the peptide stabilizer create a strong electrostatic bond. This bond keeps the active neurotoxin localized at the target nerve terminals, preventing diffusion and enhancing internalization. Clinical trials show that this peptide-stabilized formulation extends the average duration of action to approximately 6 months (24 weeks), with some patients maintaining results for up to 9 months, compared to the 3-to-4-month standard of other type-A toxins.

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Onset, duration, and the unit-conversion trap

One of the most critical concepts in neuromodulator administration is that units are not interchangeable. A "unit" is a measure of biological potency in a specific laboratory assay, not a weight metric like a microgram.

Unit Equivalencies and Ratios

The Botox-to-Dysport Ratio (1:2.5 to 1:3)

Dysport (abobotulinumtoxinA) uses a different potency assay than Botox. Clinically, one unit of Botox is not equal to one unit of Dysport. The widely accepted clinical conversion ratio is 1 unit of Botox to approximately 2.5 to 3 units of Dysport.

• If a patient normally receives 20 units of Botox in the glabellar lines, they will require approximately 50 to 60 units of Dysport to achieve an equivalent clinical effect.
• Because Dysport uses more units, the price per unit is lower (typically $4 to $6 per unit) than Botox ($12 to $16 per unit), but the total cost per treatment area remains comparable. For a detailed head-to-head comparison of these two market leaders, refer to our clinical guide on Botox vs Dysport.

The Botox-to-Xeomin / Jeuveau / Letybo Ratio (1:1)

Botox, Xeomin, Jeuveau, and Letybo share a 1:1 dosing ratio. A patient who requires 20 units of Botox will typically respond well to 20 units of Xeomin, Jeuveau, or Letybo. However, subtle differences in spread and formulation mean injectors must customize placement.

The Daxxify Dosing Protocol (1:2 ratio)

Because Daxxify is formulated differently, its approved dose for glabellar lines is 40 units, compared to the 20-unit standard for Botox. Clinically, Daxxify is dosed at a 1:2 ratio relative to Botox. This means a 40-unit Daxxify treatment contains the equivalent active toxin profile of 20 units of Botox, with the peptide stabilizer extending its duration. To explore this comparison further, see our analysis of Daxxify vs Botox.

Clinical Onset and Diffusion Profiles

• Onset Time: Most type-A toxins show initial muscle relaxation within 2 to 4 days, with the full clinical effect visible at 14 days. Dysport is often noted for a slightly faster onset (sometimes within 24 hours), which is attributed to its rapid binding profile. Daxxify also reports rapid onset, with many patients seeing results within 1 to 2 days.
• Diffusion (Spread): Dysport has a higher rate of diffusion (or "spread") in tissue compared to Botox. This makes Dysport ideal for treating broad areas like the forehead or for treating axillary hyperhidrosis. However, in narrow areas where precise muscle isolation is required (such as the brow lift or around the eyes), a low-diffusion toxin like Botox or Jeuveau is preferred to avoid accidental drooping (ptosis) of adjacent muscles.

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2026 Pipeline updates: Relfydess and Trenibote

The US neurotoxin market continues to evolve, with two major pipeline developments defining the 2026 landscape:

1. Relfydess (RelabotulinumtoxinA) — The Liquid Toxin

All currently approved neurotoxins are shipped as dry, vacuum-dried, or lyophilized powders that must be reconstituted with sterile saline in the clinic before injection. Reconstitution introduces variables: errors in dilution, potential contamination, and loss of potency if the reconstituted vial is stored too long.

Galderma’s Relfydess (developed with Ipsen) is the first ready-to-use, liquid formulation of botulinum toxin type-A.

• Regulatory Status: Relfydess has already secured regulatory approvals in more than 20 international markets, including the European Union. In the United States, the FDA accepted Galderma's BLA resubmission on February 2, 2026. A final US approval decision is anticipated later this year.
• Clinical Performance: In its Phase III READY clinical program, Relfydess demonstrated rapid onset (with some patients showing active muscle relaxation on day 1) and a prolonged duration of action, with results maintaining up to 6 months (24 weeks). By eliminating the reconstitution step, Relfydess promises consistent dosing and improved efficiency for high-volume practices. For a detailed tracking of this regulatory file, view our Relfydess liquid neuromodulator FDA review.

2. Trenibote (TrenibotulinumtoxinE) — The Serotype-E Pipeline Miss

For patients who want immediate results for an event, or those who are hesitant to commit to a 3-to-4-month result, the industry has long sought a fast-acting, short-duration toxin. This is the domain of botulinum toxin serotype E.

AbbVie/Allergan's Trenibote (formerly BTI-322) is a serotype-E neurotoxin:

• Mechanism: Serotype E cleaves a different target protein (SNAP-25) at a different site than serotype A. This translates to an ultra-fast onset, with clinical effect appearing within 8 to 24 hours (compared to 2–7 days for type A). However, its duration is short, with muscle function returning to normal in 2 to 3 weeks.
• Regulatory Status: AbbVie submitted its BLA for Trenibote on April 24, 2025. However, on April 23, 2026, the FDA issued a Complete Response Letter (CRL). The CRL was limited to manufacturing-related (chemistry, manufacturing, and controls) issues, with no concerns raised regarding the safety or clinical efficacy of the toxin. AbbVie is currently working to resolve these manufacturing queries before resubmitting the BLA. We detail these developments in our tracker on the Trenibote serotype E FDA CRL.

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Serotype A vs. B vs. E: Clinical distinctions

Understanding the differences between botulinum serotypes is essential for managing patient expectations and handling off-label indications:

Serotype A (Botox, Dysport, etc.): -> Cleaves SNAP-25. Slow onset (2-7 days), long duration (3-4 months).
Serotype B (Myobloc):             -> Cleaves VAMP/Synaptobrevin. Slow onset, short duration (2-3 months).
Serotype E (Trenibote):           -> Cleaves SNAP-25 at distinct site. Fast onset (8 hrs), short duration (2-3 weeks).

• Serotype A: The clinical workhorse. It cleaves SNAP-25, a protein essential for neurotransmitter release. It provides a slow, stable onset (2–7 days) and a long duration of action (3–4 months, or up to 6 months with Daxxify).
• Serotype B (Myobloc): Myobloc (rimabotulinumtoxinB) cleaves a different vesicle-associated membrane protein (VAMP or synaptobrevin). It has a lower pH (making the injection sting more) and a faster clearance profile, yielding a shorter aesthetic duration of 2 to 3 months. Myobloc is approved for cervical dystonia and sialorrhea but is used off-label aesthetically for patients who have developed complete antibody resistance to all serotype-A toxins.
• Serotype E: The transient option. Like serotype A, it cleaves SNAP-25, but at a different amino acid sequence. This leads to rapid uptake (onset within hours) but faster recovery of the nerve terminal (duration of 2–3 weeks). For more on the molecular science of these pathways, see our guide comparing botulinum toxin type A vs type B.

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Safety profile: FDA Boxed Warning and FAERS data

All botulinum toxin products, regardless of brand or serotype, carry a strict, class-wide FDA Boxed Warning regarding the potential for the distant spread of toxin effects.

The Boxed Warning

The warning states that the toxin can spread from the injection site to other areas of the body, causing symptoms similar to botulism. These symptoms include difficulty swallowing (dysphagia), speech disorders (dysarthria), generalized muscle weakness, and double vision (diplopia). While these complications are extremely rare in cosmetic doses (which typically range from 20 to 100 units total), they represent a real risk in high-dose therapeutic applications (e.g., treating spasticity with doses of 400+ units).

FAERS Database Analysis

To assess the real-world safety profiles of these brands, we can analyze the total adverse-event record volumes recorded in the FDA Adverse Event Reporting System (FAERS). The table below lists the cumulative adverse-event record counts for each major brand:

Cumulative FAERS Adverse-Event Records by Brand

Note: FAERS record counts are sourced from the openFDA FAERS per-brand dataset. Record volumes reflect cumulative history and market exposure (e.g., Botox has been on the market since 1989/2002, explaining its higher count), not a direct rate of occurrence or proof of causality.

Practitioners must understand that these numbers represent raw reports and are heavily skewed by market share and duration on the market. Botox, having been approved since 2002 for cosmetics (and 1989 for therapeutics), naturally features the largest volume of reports. For a deeper analysis of these safety files, see our tracker on injectable safety FAERS adverse events by brand, and our review of FDA injectable labels and boxed warnings.

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Clinical preparation: Reconstitution, dilution, and injector preferences

While the chemical properties of each neurotoxin are determined in the manufacturing facility, the final clinical performance is also heavily influenced by how the product is prepared in the office.

All FDA-approved type-A neurotoxins (with the exception of the pending Relfydess liquid formulation) are supplied as vacuum-dried or freeze-dried powders in sterile glass vials. Before injection, the provider must reconstitute the powder using 0.9% Sterile Sodium Chloride (saline).

The Saline Selection: Preserved vs. Preservative-Free

• Preserved Saline (Benzyl Alcohol): The vast majority of cosmetic injectors reconstitute neurotoxins using saline preserved with benzyl alcohol. Clinical studies have shown that preserved saline significantly reduces patient discomfort during injection because benzyl alcohol acts as a mild local anesthetic agent.
• Preservative-Free Saline: While some regulatory guidelines historically recommended preservative-free saline, it does not offer clinical advantages in patient comfort and is associated with more stinging during the injection process.

Dilution Ratios and Precision

The amount of saline added to a vial of toxin determines its concentration. For a standard 100-unit vial of Botox, Xeomin, Jeuveau, or Letybo:

• 1.0 mL Dilution: Yields a high concentration (10 units per 0.1 mL). This is favored for precise, localized injections (such as the orbicularis oculi for crow's feet or orbicularis oris for lip lines) where minimal diffusion to adjacent muscles is desired.
• 2.5 mL Dilution: Yields a standard concentration (4 units per 0.1 mL). This is the most common dilution used in clinical practice, offering a balance between precise placement and comfortable volume distribution.
• 4.0 mL or 5.0 mL Dilution: Highly diluted. This is occasionally used in advanced techniques such as "microtox" (intradermal micro-droplet injections) to treat skin quality, pore size, and mild sebum production rather than targeting deep skeletal muscle relaxation.

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Which neurotoxin is right for you?

For most cosmetic patients, the choice of brand is less important than the skill and technique of the injector. Botox, Dysport, Xeomin, Jeuveau, and Letybo perform similarly when placed correctly.

However, patients can use the following decision framework to guide their selection:

• Choose Daxxify if you want the longest-lasting result and wish to minimize your clinic visits to twice a year.
• Choose Xeomin if you are concerned about developing resistance to neurotoxins or have noticed that other brands are losing their effectiveness.
• Choose Dysport if you want a faster onset (results starting within 24–48 hours) or are treating broad areas like the forehead where a soft, diffused spread is desired.
• Choose Botox, Jeuveau, or Letybo for highly precise treatments (like a brow lift or smoothing lip lines) where localized muscle relaxation is needed without diffusion to adjacent tissues. For the financial side of these choices, see our reference on Botox price per unit vs area.

To understand the broader anatomical application of these options, including off-label uses like the Botox lip flip or general longevity parameters, see our guide on how long Botox lasts.

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Frequently Asked Questions

How many types of Botox are FDA-approved?

There are six botulinum-toxin-A products FDA-approved for cosmetic glabellar-line use in the United States: Botox Cosmetic (2002), Dysport (2009), Xeomin (2011), Jeuveau (2019), Daxxify (2022), and Letybo (approved February 29, 2024). They all work by relaxing muscle tissue but differ in their chemical formulations, active ingredients, and clinical durations.

Which type of Botox lasts the longest?

Daxxify (daxibotulinumtoxinA-lanm) is the longest-lasting FDA-approved neurotoxin, demonstrating an average duration of approximately 6 months (24 weeks) in clinical trials, compared to the 3-to-4-month standard of other type-A toxins. This is achieved through a proprietary peptide stabilizer that binds electrostaticly to nerve terminals.

Can you switch between different Botox brands?

Yes, you can safely switch between brands (e.g., getting Dysport after previously having Botox). However, because units are not interchangeable, your injector must recalculate your dose. For instance, you will require roughly 2.5 to 3 units of Dysport for every 1 unit of Botox you previously received.

What is the "naked" neurotoxin?

Xeomin (incobotulinumtoxinA) is known as the "naked" neurotoxin because it is purified to remove all accessory proteins, leaving only the active 150 kDa core neurotoxin. This formulation reduces the risk of developing neutralizing antibodies, which can make a patient resistant to botulinum toxin injections over time.

Is Letybo the same as Botox?

Letybo (letibotulinumtoxinA-wlbg) is a serotype-A neurotoxin approved in 2024 that shares a similar 900 kDa complex structure and a 1:1 dosing ratio with Botox. While chemically comparable, it is manufactured by Hugel, Inc. in South Korea and represents a new commercial option in the US market.

Why does Myobloc sting more than Botox during injection?

Myobloc is formulated at an acidic pH of approximately 5.6 to maintain the stability of the serotype-B complex in liquid solution. In contrast, type-A neurotoxins are reconstituted with physiological saline at a neutral pH of 7.4. The lower pH of Myobloc causes a transient burning or stinging sensation upon injection, which is normal and subsides within seconds.

What is the new liquid Botox in 2026?

Relfydess (relabotulinumtoxinA) by Galderma is a ready-to-use liquid neurotoxin currently approved in Europe. The FDA accepted its BLA resubmission on February 2, 2026, and a US approval decision is anticipated later this year. It eliminates the clinical need for saline reconstitution, providing consistent potency and rapid onset.

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Sources

1. U.S. Food and Drug Administration (FDA): Drugs@FDA database product registrations for Botox (BLA 103000), Dysport (BLA 125274), Xeomin (BLA 125360), Jeuveau (BLA 761085), Daxxify (BLA 761127), and Myobloc (BLA 103846). accessdata.fda.gov/scripts/cder/daf/
2. FDA Adverse Event Reporting System (FAERS): openFDA per-brand cumulative adverse-event record counts for each neurotoxin (accessed via the openFDA FAERS API). open.fda.gov/data/faers/
3. FDA Approved Prescribing Information: BOTOX (onabotulinumtoxinA) prescribing label, BLA 103000. accessdata.fda.gov/drugsatfda_docs/label/2023/103000s5327lbl.pdf
4. Hugel, Inc.: FDA Approval of Letybo (letibotulinumtoxinA-wlbg) for Glabellar Lines, February 29, 2024. hugel-inc.com/en/news/view.php?id=382
5. Galderma Laboratories: FDA Acceptance of RelabotulinumtoxinA (Relfydess) BLA Resubmission, February 2, 2026. galderma.com/news/galderma-us-fda-acceptance-relabotulinumtoxina-application
6. AbbVie / Allergan: FDA Complete Response Letter for trenibotulinumtoxinE (Trenibote) BLA, April 23, 2026. dermatologytimes.com/view/fda-issues-complete-response-letter-for-abbvie-s-rapid-onset-neurotoxin-trenibotulinumtoxine
7. American Society of Plastic Surgeons (ASPS): How does Daxxify compare to Botox? Clinical analysis and peptide stabilization study. plasticsurgery.org/news/articles/how-does-daxxify-compare-to-botox