"I have sent this email previously to [reference to Bangkok English-language newspapers] but I am aware that my warnings a valid beyond the limited time during which newspapers circulate...

"I am a 47-years-old Dutch man and have been using Botox for two years now for glabellar and forehead frown lines, as well as crowfeet. I had injections done initially in Amsterdam, which was quite expensive, though I still think that the results were worth it.

"During a holiday in Thailand, I was lured by considerably lower prices into having 'Botox' injections done locally. I had twice paid the equivalent of about 965 US dollar in Amsterdam for the injection of 100 international units of the genuine Allergan Botox product.

"At the [name omitted] clinic on [address omitted] in Bangkok, I was offered 100 international units of what I was told also was Botox, for a price of 6600 Baht, at that time slightly less than 200 US dollar.

"Well, they say that if it sounds too good to be true, it probably isn't. But being Dutch and always price-conscious, I just couldn't resist the offer. I should have.

"Here is what went wrong, and it started even before the 'Botox' injections:

"Yes, a lidocaine cream was applied to the forehead and around the eyes. But I was used to also having icepacks applied to those parts of my head that were to be injected. They did not do this at [clinic name omitted].

"At the time I underwent these 'Botox' injections in Bangkok, I wasn't very knowledgeable on the topic. I only researched extensively after I was hurt, both physically and financially, as I wanted to recover my losses, and became somewhat an expert on counterfeit 'Botox'. Of course, I should have done my homework before agreeing to the injections.

"I thought that the icepacks were intended to numb my skin for the upcoming injections. But now I know that their primary function would have been to reduce the diameter of blood capillaries and thus minimize bleeding.

"The first thing I noticed, which made me aware that for the lower price, I was also obtaining a service of lower quality, was the fact that the injections were more painful than those I received in Amsterdam, and that there was more bleeding. (Now I suspect that this was from the non-use of the icepacks as well as a lack of expertise on the part of the injecting 'physician'.)

"Over the next few days, it appeared that the injections were not as well absorbed as those I received in Amsterdam. I had what looked like swollen pimples or scratched, swollen mosquito bites at the places where the 'Botox' was injected, especially on the forehead.

"But the worst aspect was that the desired effects did not set in as expected. After a week or so, my glabellar fold should have disappeared, and I should not have been able to generate frown lines on my forehead at all. But there was just a slight reduction of the glabellar wrinkle, and it was back at full depth in less than two months.

"I went back to the clinic twice, the first time after three days to complain about the 'pimple'-like swellings on my forehead, and the second time just before my departure back to Europe, 8 days after the injections, to complain about the lack of effectiveness of the injections.

"The first time, they told me to wait a week or so, and the swellings would disappear all by themselves (which fortunately was true). The second time they told me that in a hot climate like Bangkok's, the absorption of the 'Botox' would be slower (which I now know was bullshit).

"I now know that what I received at the [name omitted] clinic was not only an inferior service, but also an inferior product. I know this because I have since become an expert on fake 'Botox' treatments.

"I acquired my knowledge at the source. Or almost at the source. In Bangkok, anyway. In spite of my bad experience with my first 'Botox' treatment, I have been back in Bangkok for other injections, at the [name omitted] hospital, where many Thai people go for cosmetic treatments (including the injection of genuine Botox).

"One of the nurses at the [name omitted] has since become my wife, and she told me what appears to be common knowledge among nurses in cosmetic treatment clinics. I used this information for further research, which is summarized in this letter.

"Counterfeit 'Botox' apparently is very common in Bangkok, and some of it is marketed through semi-official channels.

"However, one has to differentiate between different levels of 'fakeness'.

"The least fake is the use of Dysport instead of Botox. Botox, of course, is a brand name for botulinum type A toxin, produced by the US company Allergan. Dysport is also a legitimate pharmaceutical botulinum type A toxin, produced in Ireland.

"What patients and potential patients typically don't know is that Dysport is much less effective on a per-unit basis. Units of botulinum type A toxin cannot just be compared across brands. 1 unit of Botox is considerably stronger than 1 unit of Dysport, and this is internationally recognized in the medical community.

"Thus, Bangkok cosmetic clinics that advertise: botulinum type A toxin, and then give a price per 10 units without expressively stating that they are using Allergan's brand Botox may be using units of Dysport instead.

"These clinics are not selling counterfeit Botox, but they are cheating their overseas patients nevertheless.

"As a guideline, one will need something like 4 times the number of units of Dysport, compared to units of Botox, for roughly the same effect. Genuine Botox also is some four times as expensive as Dysport, again on a per-unit basis.

"But now for the real cheating... the one conducted not just by physicians who want to maximize their profits but by outright criminals.

"Botulinum toxin is not just produced and marketed by Allergan and the Irish company. It is also produced in South Korea, and, most notably, in China.

"However, the botulinum type A toxins of South Korean, and especially of Chinese origin, are not licensed anywhere outside these countries, and for the Chinese sources, it isn't even clear whether they are licensed in China itself. At least, I have not seen any documentation on these products in any language I understand (which excludes Chinese).

"But I know several Chinese addresses that sell botulinum type A toxin, and conveniently abbreviate their warez as Botox. The prices are about 10 percent of those of genuine Botox.

"As I said, I cannot judge to what extent these Chinese sources (of which I include the name and addresses below) are legitimate within China.

"But I do know that the counterfeit drugs mafia in Thailand get their supplies from China. The counterfeit drugs mafia in Thailand apparently does not produce pharmaceuticals by itself. Rather, they engage in repackaging.

"They buy cheap generic versions of questionable quality in China, and then print the fake packaging and package inserts in Thailand, and then pretend that their cheap Chinese imports are original Botox, or whatever pharmaceutical they target.

"However, these fake drug traders do not own sophisticated printing presses, and reputable printing companies that can produce top quality will shy away from printing mafia orders.

"Furthermore, the term counterfeit drug mafia is somewhat misleading for the situation in Bangkok. Sure, dealing in fake pharmaceuticals is a more organized criminal activity than spontaneous armed robbery, and the term commonly used for organized crime is 'mafia'.

"But the trade in counterfeit Botox, or in counterfeit pharmaceuticals in general, seems not to be conducted by just one criminal organization, a real Mafia. Rather, smaller entities seem to be involved, which are not mafia-type in that they are not heavily armed.

"Rather, they apparently understand themselves as traders of cheap generic medications, who undermine the monopolies of international pharmaceutical corporations.

"Nevertheless, the products they sell clearly are counterfeits, and because the counterfeits in this case are not just decorative items, such as Rolex watches or Gucci handbags, but products that have a direct impact on a person's health (typically negative), and because, furthermore, the patients who are injected a cheap Chinese botulinum type A toxin, rather than genuine Botox, are usually not aware of the substitution, fake Botox injections are far worse a crime than the sale of fake Rolex watches.

"Therefore, it is deplorable that the Thai police does not act more decisively against so-called cosmetic treatment clinics that target price-concerned foreign medical tourists with offers of cheap 'Botox' treatments.

"Here a list of Chinese addresses that offer cheap botulinum type A toxins for cosmetic treatments. These addresses are among those from where the traders of counterfeit 'Botox' get their raw materials.

Chinese botulinum type A toxin traders

Mr. JIMMY Deng (Manager)
Phenix Medical Co.,Ltd
Tianhe, Guangzhou, China
86-020-13129401689

Mr. Cruise Yao (Manager)
Hunan Hormones Pharmaceuticals
Pudongnan Rd, Shanghai, China
86-21-58406787

Ms. Linda Deng (Marketing)
Jingmen Kaitai Pharmaceutical Co., Ltd.
Duodao District, Jingmen, Hubei, China
86-724-6691579

Mr. Cruise (Manager)
Shanxi SteroidsFarma Co.
Zhangyang Rd, Shanghai, China
86-21-50464056

Mr. Bill King (CEO)
Shandong Biomedicine Company
Erhuandong Road, Jinan, Shandong, China
86-135-73779821