I can't get hold of any Azzalure - what should I do?

With the recent shortage in supply of Azzalure, we have been inundated with queries from those practitioners who solely use Azzalure, regarding the use of other botulinum toxins and in particular their reconstitution protocols.

To this regard this blog will discuss the use of Bocouture and Botox with a focus on their reconstitution.

What are the differences between Azzalure, Bocouture and Botox?

Azzalure, Botox and Bocouture are the 3 Botulinum Toxin Type A medicines that are available in the UK for cosmetic use. These all contain the same active agent - Botulinum Toxin and so broadly speaking pharmacologically act similarly.

There are slight differences in respect to the amount of non-active proteins and excipients (items added to help with the stability of the product). The important point is that clinically there are no significant difference in clinical effect of the various preparations.

Bocouture is not involved in the cold chain and does not have to be refrigerated. This can ease the logistics.

Licensed use

Azzalure is indicated for Glabellar lines (vertical lines between the eyebrows) seen at maximum frown and/or Lateral canthal lines (crow's feet lines) seen at maximum smile

Injecting the forehead is technically off-license.

Bocouture and Botox licences indications include the forehead also (i.e. Glabellar lines, Lateral canthal lines and Horizontal forehead lines).

Relative potency

In relative terms the equivalent of a 125 Speywood Units (SU) vial of Azzalure is a 50 unit vial of Bocouture or Botox.

Therefore for 1 unit of Botox or Bocouture has the equivalent approximate potency of 2.5 SU of Azzalure.

So where an injector would typically place 10 SU of Azzalure they would need to inject 4 units of Bocouture or Botox to achieve a similar outcome. To get the specific manufacturers recommendations see the links to the Summary of Product Characteristics in the next section.

Injection sites and doses

For further information regarding this see the Summary of Product Characteristics for each of the brands:

Azzalure: https://www.medicines.org.uk/emc/medicine/21985#gref

Botox: https://www.medicines.org.uk/emc/product/6185/smpc

Bocouture: https://www.medicines.org.uk/emc/medicine/23251#gref


A vial of Azzalure is 125 SU. Although technically you can reconstitute Azzalure with 1.25ml of sodium chloride 9 mg/ml (0.9%) solution for injection, most of you that are using Azzalure use 0.63ml. This means that there are 10 SU per 0.05ml.

The difference is that with Botox or Bocouture the 50 units is reconstituted in 1.25ml of sodium chloride 9 mg/ml (0.9%) solution for injection (i.e. double what is used with the Azzalure). This means that there are 4 units per 0.1ml

For those of you who use a 1ml graduated syringe with a 30g needle this is a relatively straight forward process.

Once you reconstitute with 1.25ml of sodium chloride 9 mg/ml (0.9%) solution for injection you would need to inject 0.05ml to administer 2 units (ie the equivalent to where you would place 5 SU of Azzalure) or 0.1ml to administer 4 units (ie the equivalent to where you would place 10 SU of Azzalure)

For those of you using Azzalure, you may be well versed in the use of the following green syringe provided: