The UK Health Security Agency (UKHSA) has reported an investigation into a series of iatrogenic botulism cases associated with cosmetic botulinum toxin injections across England. Between 4 June and 14 July 2025, a total of 38 cases were identified, with the majority (29) concentrated in the North East region.

 

What is Iatrogenic Botulism?

Iatrogenic botulism is a rare but serious condition caused by the unintended spread of botulinum neurotoxin beyond the injection site. This can lead to systemic symptoms including muscle weakness, difficulty swallowing, and respiratory issues. While botulinum toxin is widely used in therapeutic and cosmetic procedures, excessive amounts or unregulated products may increase the risk of this adverse event.

 

Patient Demographics and Symptoms

Of the 38 cases, 32 (84%) were female and 6 (16%) were male, ranging in age from 25 to 82 years, with a median age of 42. Symptoms typically began within 1 to 3 days after injection, though onset ranged from the same day to up to 11 days post-procedure. The most frequently reported symptoms included ptosis (drooping eyelids) or blurred vision (68%), and difficulty swallowing (57%). Notably, 6 individuals required admission to critical care for respiratory support.

 

Settings and Products Involved

Injections were reported in various settings, including practitioners’ homes (45%), salons or clinics (26%), and patients’ own homes (26%). There was one case where the setting was unknown. Many of the botulinum toxin products involved were unlicensed and reportedly manufactured in South Korea. Thirteen cases were unable to specify the brand of product used.

 

Public Health Response

UKHSA is collaborating with regulatory bodies including the Medicines and Healthcare products Regulatory Agency (MHRA), Office for Product Safety & Standards (OPSS), local authorities, and the police to investigate the cause of these outbreaks and identify any links between products and practices. A trace-back of implicated botulinum toxin products is underway.

 

Clinical Guidance

Diagnosis of iatrogenic botulism is primarily clinical due to limitations in laboratory testing. Prompt recognition and treatment with botulinum antitoxin (BAT), along with supportive care, are essential, especially in cases with systemic symptoms such as difficulty breathing or swallowing. Six patients have required intensive respiratory support, highlighting the potential severity of this condition.

 

Healthcare professionals are advised to discuss suspected cases urgently with the Colindale Duty Doctor at 0208 200 4400 and report cases to their local Health Protection Team. Serum samples should be collected prior to antitoxin administration and sent to the Gastrointestinal Bacteria Reference Unit for testing, although laboratory diagnosis has low sensitivity.

 

Advice for the Public and Practitioners

UKHSA recommends that individuals considering cosmetic botulinum toxin injections ensure procedures are performed by qualified practitioners in regulated clinical settings using licensed products. Awareness of the risks and prompt medical attention if symptoms develop post-injection are crucial.