Rumour: “Botulinum toxin (commonly called ‘botox’) and fillers are addictive; once you start, you cannot stop” — What does the science say?

Short answer: no, they are not addictive in the physical sense. Botulinum toxin and hyaluronic acid filler are products that act in the area where they are placed; when they are stopped, no withdrawal symptoms are seen and the face does not become worse than before. Because their effects are temporary, those who want to maintain the result repeat the procedure; this is not addiction. On the other hand, in some people a gradual shift in how they perceive their appearance and a steadily increasing wish for procedures is a real risk and needs to be recognised.

Where does the rumour come from?

The rumour has three sources. The first is that these procedures are repeated at certain intervals; seen from outside, this can look like 'not being able to stop'. The second is the difference a person sees in the mirror when the effect wears off: after months of getting used to a face that looks more rested, the return of the old lines can create the feeling of 'I look worse than before'. The third is that people who really do want more each time, and whose faces take on a markedly exaggerated appearance, are in the public eye.

The first two are a misunderstanding. The third is real, but its cause is not the product itself; it has to do with perception and behaviour.

What does addiction mean, and is it present with these procedures?

When substance dependence is discussed in medicine, features are looked for such as tolerance, that is, needing more and more of the substance for the same effect, and physical withdrawal symptoms that appear when the substance is stopped. Botulinum toxin temporarily reduces the nerve signal reaching the muscle into which it is injected; hyaluronic acid filler is a gel that provides volume where it is placed and is absorbed by the body over time. No effect of these products on reward or habit formation in the brain has been described; nor has any withdrawal picture, such as tremor, restlessness or pain, been reported when their effects wear off.

So the saying 'once you start, you cannot stop' is not true in physical terms. You can stop whenever you wish; nor does stopping require any process such as 'coming off' the product or tapering it.

Is repeating it because the effect is temporary an addiction?

No. According to dermatology sources, the effect of botulinum toxin on lines lasts about three to four months in most people. The effect of hyaluronic acid fillers varies with the product and the area and is generally expressed in months. Health authorities also state that with absorbable fillers the procedure may need to be repeated after a while for the desired effect to continue.

Seen in this light, repetition resembles having your hair coloured or your teeth cleaned at certain intervals: the result is temporary, and a person who wants it to continue has the procedure repeated. Doing something regularly does not turn it into an addiction. What is decisive is not the frequency but whether the person remains in control of it.

There is a point here on which honesty is needed: health authorities state that the safety of using fillers repeatedly over many years has not been evaluated in controlled studies. This does not mean that repetition is harmful; however, it is a good reason for the intervals and the amount to be set each time according to an examination, not according to habit. For the properties of the products, see our article “Botulinum Toxin or Filler? The Differences and What Each One Is Used For”.

If you stop, does the face become worse than before?

It does not. When the effect of botulinum toxin wears off, the muscle begins to move again and expression lines return over time to how they were before the procedure. This is not the lines becoming 'worse' but the temporary effect coming to an end. Dermatology sources state that repeated treatments can thin the muscle and that this can lead to the effect lasting longer. A review on the subject also reports that muscle thinning due to botulinum toxin is temporary and reverses when treatment is stopped.

The position is similar for filler. We have covered this in detail in our article “Rumour: If you stop fillers, your face will sag more than before — What does the science say?”: there is no strong evidence that stopping filler makes the face sag more than before. What is misleading is the comparison. Over the years in which the procedures continue, age also advances; the appearance after stopping should be compared not with photographs from years ago but with one's age on that day.

When you decide to stop, there is nothing you need to do; it is enough not to have any new treatment. The effect of botulinum toxin fades on its own over months. Hyaluronic acid filler is also absorbed over time; filler that is out of place or causing discomfort needs a physician's assessment.

The real risk: a shift in perception and a steadily increasing wish for procedures

This is where the true part of the rumour lies. A person who gets used to their new appearance comes, after a while, to regard it as 'normal', and the same result no longer feels sufficient. In this situation, referred to in the literature as perception drift, the measure of a 'natural face' in the person's mind changes without their noticing.

In a qualitative study based on interviews with 24 women who had had lip filler to a markedly exaggerated degree, four main themes emerged: the normalisation of lip filler, repeated viewing of images of large lips on social media shifting perception, the belief that large lips would bring social and financial benefit, and the relationship between mental health and seeking repeated procedures. This is a small and deliberately selected group; no generalisation can be made to everyone who has filler, and it does not show causation. Even so, it is valuable for understanding the mechanism.

Perception drift can affect not only the person having the procedure but also those around them and the practitioner; an eye that constantly sees altered faces can begin to regard them as normal. For this reason, a physician who exercises restraint and can say 'this is enough' when necessary is an important safeguard. For details specific to the lips, see our article “Lip Filler”.

There is also a separate, more serious condition. If worry about appearance takes up most of the day, restricts life and does not lessen with the procedures carried out, a treatable mental health problem called body dysmorphic disorder may be involved. This condition is more common among people seeking aesthetic procedures than in the general population, and research shows that in this condition aesthetic procedures mostly do not relieve the worry. The details are in our article “Body Image and Aesthetic Treatments”.

Which signs are a warning?

The following are not diagnostic criteria but signs that you should stop, think and talk to your physician.

If several of these signs seem familiar to you, this is a reason not to blame yourself but to talk to a physician or a mental health professional. If you have thoughts of harming yourself, call 112 (or your local emergency number) without waiting, or go to the nearest emergency department.

What can be done to stay in control?

• At the first consultation, discuss your aim and where you will stop with your physician; follow the plan according to this aim, not according to what you want on the day.
• Set the timing of repeat treatment according to the findings on examination, not according to the calendar or to announcements.
• Make the decision by looking in the mirror; do not take filtered images or someone else's face as your measure.
• Looking at the medical record photographs taken by the facility before and after the procedure helps you remember where you started.
• Listen to the honest opinion of someone close to you whom you trust.
• Choose a physician who is able to say 'no'; a practitioner who accepts every request without question does not protect you.
• Do not be afraid to take a break; taking a break does not spoil the result, it only allows the effect to fade.

We cover the subject of treatments that begin at a young age and turn into a habit in our articles “Rumour: Starting botulinum toxin (commonly called botox) at a young age prevents wrinkles — What does the science say?” and “Medical Aesthetics for Young People”.

Conclusion

Botulinum toxin and hyaluronic acid filler do not cause physical dependence; there is no withdrawal when they are stopped, and the face does not become worse than before. The procedures are repeated because the effect is temporary. What calls for attention is not the product itself but perception, which can shift over time: when the wish for more frequent treatment, larger amounts and more areas increases, it is time to stop and take stock. A measured plan, intervals based on examination and a physician who can say 'enough' when necessary reduce this risk.