Botulinum Toxin and Dermal Filler: Discordant Legislation, Regulations, and Guidelines in the United States

BACKGROUND Botulinum toxin and dermal filler injections are the most commonly performed minimally invasive cosmetic procedures in the United States. These injectables require extensive medical training, experience, and oversight to be administered safely due to risk of significant complications. However, rules and regulations governing their administration differ widely across states. OBJECTIVE To summarize the legal statutes, regulations, codes, and professional guidelines governing administration of botulinum toxin and dermal filler injections in the United States using sources from legal databases, scholarly search engines, state government websites, and the American Society for Dermatologic Surgery Association (ASDSA). METHODS WestLaw, LexisNexis, PubMed, Google Scholar, and state government websites were searched using key terms. ASDSA Patient Safety Resources and referenced source materials were examined for each state and the District of Columbia. Relevant material from January 1, 2000 to December 31, 2024 published in English was recorded. RESULTS Substantial variability exists among states in scope of practice restrictions, medical supervision, and oversight requirements for cosmetic injectables. Several states have no specific regulations in this area. CONCLUSION Inconsistent or absent state regulations may jeopardize patient safety. The technical skill and potential risks associated with cosmetic injectables warrants consistent national standards surrounding their administration. Significant state-to-state variation in provider scope of practice supervision requirements highlights the need for clear, consistent legislation that clarifies provider roles, establishes minimum competency standards, and prioritizes patient safety.