The Alabama Board of Medical Examiners (“the Board”) has learned of a recent decision by the Alabama Board of Nursing (“ABN”) to issue a declaratory ruling to a registered nurse (“RN”) indicating that the RN may administer botulinum toxin and its analogues for cosmetic purposes.

The Board has previously held that the administration of botulinum toxin for cosmetic purposes constitutes the practice of medicine. While the Board, in conjunction with the Joint Committee for Advanced Practice Nursing and the Physician Assistant Advisory Committee, has recently approved a protocol enabling qualified and properly trained certified registered nurse practitioners (“CRNPs”) and physician assistants (“PAs”) to administer botulinum toxin and its analogues for cosmetic purposes, the protocol does not permit further delegation of these procedures. Accordingly, the Board has not authorized the performance by, or delegation of this skill to, any person other than a PA or CRNP acting pursuant to a collaboration/registration agreement and the approved protocol.

Any physician who delegates the administration of botulinum toxin to an RN or any provider other than a PA or CRNP operating under an approved protocol, or permits a CRNP or PA with whom they are in a collaborative/supervisory relationship to delegate this skill, will not be acting in accordance with the approved protocols and may be in breach of the standard of care.

The Board further cautions all licensees that a declaratory ruling only binds the issuing agency (in this case, the ABN) and the person requesting the ruling (the individual RN). See Ala. Code § 41-22-11. The ABN’s ruling may not provide any legal protection in a malpractice action or an administrative proceeding before the Board and Medical Licensure Commission.