Counterfeit Botox Is Making People Sick—Here’s How to Spot an Unlicensed Injector

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Counterfeit Botox has been distributed in the United States, affecting 19 people in Colorado, Florida, Illinois, Kentucky, Nebraska, New Jersey, New York, Tennessee, and Washington, according to an April 15 CDC press release.

The 19 individuals reported adverse reactions to counterfeit Botox, with nine undergoing hospitalization for conditions such as blurred vision, difficulty swallowing, dry mouth, constipation, fatigue, and shortness of breath. Before you panic about getting injections overall however, there are some key details you should consider.

The people impacted—all of whom were from the ages of 25 to 59 and received Botox “for cosmetic purposes” (as in, not to treat a condition like migraines or excessive sweating)—were injected by untrained and unlicensed injectors in nonmedical settings, such as at home and in med spas.

Translation? If you see a trained, licensed, and reputable injector, you shouldn't have to worry about counterfeit Botox. It's unclear whether these women knew the extent of their injectors' qualifications, though this proves that while it never hurts to ask, sometimes it does hurt to not.

Fortunately, none of the reported fake Botox cases resulted in death. Those hospitalized were successfully treated with “botulism antitoxin,” a medication prescribed to treat symptoms of botulism, while five of the 19 reported were tested for botulism—a rare type of poisoning that can be caused by toxins and cause paralysis, per Mayo Clinic—but tested negative.

The counterfeit Botox is now being investigated by the CDC, the US Food and Drug Administration (FDA), and several state and local health departments.

Ahead, dermatologists and plastic surgeons break down exactly what you need to know about counterfeit Botox as well as how to spot it ahead of time.

Counterfeit Botox side effects

“People injected with the counterfeit product have reported visual changes, drooping eyelids, difficulty swallowing and breathing as well as slurred speech, dry mouth, fatigue, and generalized weakness,” Rukmini Rednam, MD, a board-certified plastic and reconstructive surgeon, tells Glamour. “These symptoms are very similar to how botulism can present, which is when botulinum toxin has a systemic or whole-body effect.”

Actual, and properly administered, Botox should not give you these side effects. “Authentic Botox cosmetic has a local effect on the muscles targeted and does not present with systemic symptoms,” Dr. Rednam says.

Where did counterfeit Botox come from?

“There are a lot of counterfeits out there; I believe most of them are made in China,” says board-certified cosmetic dermatologist Paul Jarrod Frank, MD. As for how people get their hands on them? “They can be ordered online, and these products tend to be used by people who aren't licensed to use the prescriptive products.”

In short, if someone is licensed to administer Botox, they have no reason to seek it out. “You need to be a physician to order them, so an unlicensed provider that wants to acquire the drug and inject illegally would get a counterfeit source,” he explains. “There are licensed providers who, to cut corners and try to get things very cheap, would get counterfeit substances, but most people (certainly in the United States) with a registered license to practice medicine at any level would unlikely risk their license to buy counterfeit Botox.”

How to know you’re seeing a licensed injector

Check credentials.

“You need to know you're going to a licensed health care provider,” says Dr. Frank. “Are they a doctor? Are they a nurse? Are they a physician assistant? If they are an esthetician or anything else, they are not licensed to purchase or inject any form of legal or illegal Botox.”

While injector eligibility also differs state by state, you typically want to find a physician (MD or DO), nurse practitioner (NP), physician assistant (PA), registered nurse (RN), or dentist (DMD or DDS).

“In rarer cases, aestheticians may be legally allowed to perform cosmetic injections,” says Rachel Westbay, MD, board-certified dermatologist at Marmur Medical, while nonphysician injectors may be required to have physician oversight. “However, just because an injector is legally allowed to offer cosmetic injections does not mean they have the medical knowledge or aesthetic sensibility to provide excellent and safe outcomes,” she clarifies.

Research online.

Don't take just your injector's word for it; look them up online. “Word of mouth is important, but unfortunately, that's how counterfeit injectors get most of their patients: solely through word of mouth,” Dr. Frank says. “Always do research on the name of the injector.”

Remember: Having thousands of Instagram followers does not necessarily mean someone's qualified: “Word of mouth and personal referrals should be one of the most important factors in selection, much more so than social media presence,” says Dr. Westbay.

Ask what you’re having injected.

Once you've made sure you're being treated by a licensed health care provider, find out what type of botulinum toxin you're having injected in you. “There are several brand names: Botox, Xeomin, Dysport, Jeuveau, Daxxify,” Dr. Frank says. “There are five in the U.S. market. For people that are very unsure or cautious, you could even ask to see the bottle.” No licensed injector is going to have a problem with your double-checking.

Receive Botox only in medical settings.

“The number one red flag would be an injection performed by someone who is not board-certified in an aesthetic specialty or one that does not take place in a formal medical setting,” says Dr. Westbay. “For instance, Botox parties are becoming increasingly popular. These injection parties, which happen in someone’s home, are a real risk. It is not uncommon for the injector in this circumstance to not practice an aesthetic specialty (derm, plastics) and not have received any formal, thorough training in the subject.”

According to Dr. Westbay, “These injectors are more likely to seek a discounted product of unknown source, which is more likely to be counterfeit.”

The same is true of cosmetic tourism, she adds, meaning “those who travel abroad to seek discounted rates on cosmetic procedures.” These practitioners are more likely to obtain products from an untrusted, illegitimate source.

If the price is too good to be true, it probably is.

“Often, if the cost seems too good to be true, it probably is,” Marisa Garshick, MD, a board-certified dermatologist at at MDCS Dermatology, says of inauthentic injectors. “When practices purchase Botox, or other neuromodulators, from the company that manufactures it, there is a cost to the product. If someone is able to charge less than the product actually costs to purchase, it is important to question how they are getting it, and chances are it is because they are not getting the product from a reputable source.”

And if it seems especially pricey, consider it this way: “You are not purchasing a syringe of Botox; you are purchasing the skill and expertise of the person administering it,” says Dr. Westbay. “It’s extremely important: How could it not be? This is your face we are talking about, and I would think someone paying electively for a procedure that isn’t medically necessary and is strictly performed to improve his or her appearance would want the best possible outcome.”

All med spas are not created equal.

“Med spas are becoming an increasingly more popular choice for injections because they are cheaper,” says Dr. Westbay, though she cautions consumers before choosing to get injectables there. “If you’re going to pursue injections at a med spa, do your research, as not all are created equal and some are seriously questionable.”

At the end of the day, visiting an actual physician's office is always the safest option. “It’s important to understand that there are inherent differences between med spas and physicians’ offices that deserve merit,” she says. “I can guarantee the product used at a board-certified dermatologist or plastic surgeon will be FDA-approved and not counterfeit. I cannot guarantee that to be the case in med spas.”

Dr. Garshick agrees, recommending you search for board-certified dermatologists and plastic surgeons via the American Academy of Dermatology or American Society of Dermatologic Surgery websites. “If your injections are performed at the office of a board-certified dermatologist or plastic surgeon, I can guarantee you the person standing behind that syringe underwent extensive training,” says Dr. Westbay.

There are also directories and apps like RealSelf, which verifies doctors' medical licenses every three months and lists their board certifications so you can easily find what they're certified in. RealSelf also features unedited before-and-after photos and requires doctors to maintain a minimum satisfaction rating of four out of five stars.

How to spot counterfeit Botox

According to Dr. Rednam, the biggest injector red flag is finding no information about them online.

Other things to watch out for? Not collecting Botox with a syringe in front of you; not intaking proper medical history before injection; being injected in a home, a hotel, or a nonmedical spa; using a pen device to inject; not being offered a follow-up or a way to see the injector again; and if their facility does not display certification upon request.

“On that note, please be wary of marketing scams,” says Dr. Westbay. “Does the injector have ‘master injector’ written on their Instagram profile or website? This title may sound appealing, but this is actually a ‘made-up’ term that some clinicians self-label themselves as. In truth, there are no classes or certifications that any doctor or nurse can take to certify themselves as a ‘master injector.’”

When it comes to injections, it's better safe than sorry. “It's important for consumers to be educated,” Dr. Frank concludes. “With the cosmetic boom that exists, we can't just assume that every person performing esthetic procedures is going to be legitimate.”

Danielle Sinay is the associate beauty editor at Glamour. Follow her on Instagram @daniellesinay.

Originally Appeared on Glamour