Who may inject Botox and hyaluronic acid? The legal situation for physicians, dentists and Heilpraktiker (non-medical practitioners)

Botulinum toxin and hyaluronic acid fillers are among the most common aesthetic treatments – and among those where there is the most uncertainty about who may perform them. The answer depends on what is injected: botulinum toxin is a prescription-only medicinal product, hyaluronic acid fillers are medical devices. Different rules apply to each.

The short answer for Germany

• Physicians: may do both. The licence to practise medicine is sufficient; a specialist title is not required.
• Dentists: only within the scope of dentistry – that is, in the area of the teeth, mouth and jaw. Wrinkle treatments on the face are not permitted.
• Heilpraktiker (non-medical practitioners): hyaluronic acid fillers yes; botulinum toxin no, in the view of the State Chambers of Physicians (Ärztekammern).
• Beauticians: neither.

Botulinum toxin: prescription-only and reserved for physicians

Under section 48 of the German Medicinal Products Act (Arzneimittelgesetz), botulinum toxin may only be supplied on prescription from a physician or dentist. The summaries of product characteristics of authorised preparations also stipulate that they are to be used only by physicians with suitable qualifications.

Is a specialist title required? No. In 2011, the Federal Constitutional Court (Bundesverfassungsgericht) made clear that the licence to practise medicine entitles physicians to treat patients in all fields it covers – irrespective of specialisations. The German Medical Association (Bundesärztekammer) reaffirmed this in 2026: specialist training is not required; for liability purposes, all that counts is that the specialist standard of care was observed. Anyone who performs aesthetic injections must therefore have the skill expected of a specialist – regardless of which specialist training he or she has.

And Heilpraktiker? There is no express statutory prohibition on their using botulinum toxin. However, Heilpraktiker (non-medical practitioners) cannot prescribe the medicinal product and therefore cannot obtain it legally; in addition, there is the restriction in the summary of product characteristics. The State Chambers of Physicians (Ärztekammern) therefore consider use by Heilpraktiker to be impermissible – most recently the Hesse State Chamber of Physicians (Landesärztekammer Hessen) in April 2026.

Hyaluronic acid fillers: practice of medicine, but not reserved for physicians

Wrinkle injection treatment constitutes the practice of medicine (Heilkunde) within the meaning of the German Non-Medical Practitioners Act (Heilpraktikergesetz). This was decided by the Higher Administrative Court of North Rhine-Westphalia (Oberverwaltungsgericht Nordrhein-Westfalen) in 2006; in 2007, the Federal Administrative Court (Bundesverwaltungsgericht) confirmed that a cosmetic aim does not change this. It follows that:

• Heilpraktiker (non-medical practitioners) may inject fillers. German law does not so far reserve this to physicians. The German Medical Assembly (Deutscher Ärztetag) called for such a reservation in 2013; according to our research, there is no draft bill to that effect.
• Beauticians may not. Anyone who injects fillers without a licence to practise medicine and without a Heilpraktiker permit commits a criminal offence under section 5 of the German Non-Medical Practitioners Act (Heilpraktikergesetz). In 2012, the Higher Regional Court of Karlsruhe (OLG Karlsruhe) emphasised that injecting requires knowledge of the course of blood vessels, nerves and muscles.

The situation is inconsistent for needle-free devices: in 2025, the Administrative Court of Düsseldorf (Verwaltungsgericht Düsseldorf), in interim proceedings, did not classify a needle-free system as the practice of medicine (Heilkunde); by contrast, the Baden-Württemberg State Health Office (Landesgesundheitsamt Baden-Württemberg) classifies so-called hyaluron pens as the practice of medicine.

Dentists: teeth, mouth and jaw only

Under section 1(3) of the German Dentistry Act (Zahnheilkundegesetz), dentistry comprises the diagnosis and treatment of diseases of the teeth, mouth and jaw. From this, the Higher Administrative Court of North Rhine-Westphalia (Oberverwaltungsgericht Nordrhein-Westfalen) concluded in 2013: a dentist is not entitled to inject wrinkles outside the area of the teeth, the mouth including the lips, and the jaw. Botulinum toxin in the facial area and the treatment of perioral wrinkles and of the nasolabial folds were also expressly rejected. In 2014, the Federal Administrative Court (Bundesverwaltungsgericht) saw no further need for clarification: the question could readily be answered in the negative on the basis of the statute. In 2017, the Higher Administrative Court even upheld the revocation of a licence to practise after repeated convictions.

• Lips: The German Dental Association (Bundeszahnärztekammer) considers lip augmentation to be covered by dentistry. The court itself did not rule on the lips in 2013.
• Bruxism: According to the German Dental Association (Bundeszahnärztekammer), the injection of botulinum toxin can be part of dental therapy. It is performed outside the marketing authorisation (off-label) and has not yet been clarified by the higher courts.
• Additional Heilpraktiker permit: It widens the scope for fillers outside the oral area, but not for botulinum toxin. The two activities must be recognisably separate for patients.
• Oral and maxillofacial surgeons with a licence to practise medicine are, as physicians, not subject to any such limit.

We have summarised what this means for training under Botulinum toxin for dentists.

Delegation: indication and informed consent remain with the physician

Whether the injection of botulinum toxin may be delegated to medical assistants is not expressly regulated. According to the statement by the German Medical Association (Bundesärztekammer) and the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung), history-taking, establishing the indication, informing the patient, the treatment decision and the performance of invasive therapies are services that the physician must provide in person. Together with the restriction in the summary of product characteristics, everything speaks in favour of performing the injection yourself.

Advertising: before-and-after pictures are off limits

Under section 10 of the German Act on Advertising in the Health Care System (HWG), prescription-only medicinal products may be advertised only to physicians, dentists, veterinarians, pharmacists and the pharmaceutical trade – not to patients. For hyaluronic acid treatments, the Federal Court of Justice (BGH) ruled on 31 July 2025 that injections in the nose and chin are operative plastic-surgical procedures within the meaning of the Act – before-and-after pictures aimed at laypersons are therefore prohibited. A constitutional complaint has been lodged against the judgment. For botulinum toxin, the Federal Court of Justice has not decided the question.

Austria and Switzerland

Austria: Under the Act on Aesthetic Treatments and Operations, aesthetic treatments are activities reserved for physicians, expressly including the use of medicinal products such as botulinum toxin. According to the City of Vienna, fillers in the face may only be injected by physicians.

Switzerland: Botulinum toxin is prescription-only; according to Swissmedic, beauticians are not entitled to use it. Fillers that remain in the body for more than 30 days may only be used by physicians, or by qualified nurses with further training under the direct supervision and responsibility of a physician; cantonal law remains reserved.

Titles: there is no such thing as a “specialist in aesthetic medicine” (Facharzt für ästhetische Medizin)

Being permitted to perform aesthetic treatments does not mean that you may call yourself whatever you like. In May 2026, the Higher Regional Court of Hamm (OLG Hamm) prohibited the designation “Fachärzte für ästhetische Medizin” (specialists in aesthetic medicine) as misleading, because consumers understand it to mean specialist training recognised by the professional supervisory body; an appeal on points of law has been admitted. In early 2026, the Higher Regional Court of Frankfurt am Main (OLG Frankfurt am Main) even objected to the designation “Arzt für Ästhetische Medizin” (physician for aesthetic medicine) used by a specialist in general medicine; according to the Wettbewerbszentrale (German Centre for Protection against Unfair Competition), this judgment is not final. What this means for how you present yourself to the public is set out in the guide Learning aesthetic medicine.

The most important decisions at a glance

• Federal Constitutional Court (Bundesverfassungsgericht), 1 February 2011 – 1 BvR 2383/10: The licence to practise medicine entitles physicians to treat in all fields it covers, irrespective of specialisation.
• Higher Administrative Court of North Rhine-Westphalia (Oberverwaltungsgericht Nordrhein-Westfalen), 28 April 2006 – 13 A 2495/03: Wrinkle injection treatment constitutes the practice of medicine (Heilkunde).
• Federal Administrative Court (Bundesverwaltungsgericht), 25 June 2007 – 3 B 82.06: A cosmetic aim does not change the classification as the practice of medicine (Heilkunde).
• Higher Regional Court of Karlsruhe (OLG Karlsruhe), 17 February 2012 – 4 U 197/11: Injecting requires knowledge of the course of blood vessels, nerves and muscles; it is not permitted without a licence to practise medicine or a Heilpraktiker permit.
• Higher Administrative Court of North Rhine-Westphalia (Oberverwaltungsgericht Nordrhein-Westfalen), 18 April 2013 – 13 A 1210/11: Dentists may not inject wrinkles outside the area of the teeth, mouth and jaw.
• Federal Administrative Court (Bundesverwaltungsgericht), 17 January 2014 – 3 B 48.13: No further need for clarification regarding this limit of dentistry.
• Higher Administrative Court of North Rhine-Westphalia (Oberverwaltungsgericht Nordrhein-Westfalen), 17 May 2017 – 13 A 168/16: Revocation of a licence to practise after repeated convictions upheld.
• Administrative Court of Düsseldorf (Verwaltungsgericht Düsseldorf), 12 June 2025 – 20 L 1075/25: In interim proceedings, a needle-free system was not classified as the practice of medicine (Heilkunde).
• Federal Court of Justice (BGH), 31 July 2025 – I ZR 170/24: Injections in the nose and chin are operative plastic-surgical procedures within the meaning of the German Act on Advertising in the Health Care System (HWG); before-and-after pictures aimed at laypersons are prohibited.
• Higher Regional Court of Hamm (OLG Hamm), 12 May 2026 – 4 UKl 3/25: “Fachärzte für ästhetische Medizin” (specialists in aesthetic medicine) is misleading; appeal on points of law admitted.

Conclusion for practice

Botulinum toxin belongs in the hands of physicians; for fillers, German law reserves treatment to those authorised to practise medicine (Heilkundevorbehalt), not to physicians alone (Arztvorbehalt). Dentists remain limited to the teeth, mouth and jaw. Licensed physicians do not need a specialist title – but they do need a qualification that meets the specialist standard of care.

This is exactly what structured training is for: anatomy, technique and complication management before the first patient is treated. You will find an overview of our courses under Botox course for physicians; the checklist for injection courses shows how to recognise a good course.

Frequently asked questions

Are Heilpraktiker allowed to inject Botox?

In the view of the State Chambers of Physicians (Ärztekammern), no. Botulinum toxin is prescription-only; Heilpraktiker (non-medical practitioners) cannot prescribe it and therefore cannot obtain it legally; the summaries of product characteristics provide for use by physicians. However, there is no express statutory prohibition on its use.

May dentists inject Botox?

Only within the scope of dentistry. According to the case law of the Higher Administrative Court of North Rhine-Westphalia (Oberverwaltungsgericht Nordrhein-Westfalen), dentists are not permitted to perform wrinkle treatments on the face. According to the German Dental Association (Bundeszahnärztekammer), the treatment of bruxism can be part of dental therapy; it is performed outside the marketing authorisation (off-label) and has not been clarified by the higher courts.

Are beauticians allowed to inject hyaluronic acid?

No. Wrinkle injection treatment is the practice of medicine (Heilkunde) and is therefore reserved for physicians and Heilpraktiker (non-medical practitioners) (Higher Administrative Court of North Rhine-Westphalia 2006, Higher Regional Court of Karlsruhe 2012).

Does a physician need a specialist title for aesthetic injections?

No. The licence to practise medicine is sufficient. For liability purposes, however, the treatment must meet the specialist standard of care.

Sources

• German Medicinal Products Act (Arzneimittelgesetz), section 48; Ordinance on Prescription-Only Medicinal Products (Arzneimittelverschreibungsverordnung), section 1; Non-Medical Practitioners Act (Heilpraktikergesetz), sections 1, 5; Dentistry Act (Zahnheilkundegesetz), section 1(3); Act on Advertising in the Health Care System (Heilmittelwerbegesetz), sections 10, 11.
• Federal Constitutional Court (Bundesverfassungsgericht), order of 1 February 2011 – 1 BvR 2383/10. German Medical Association (Bundesärztekammer), statement of 26 June 2026 in proceedings 1 BvR 2656/25.
• Higher Administrative Court of North Rhine-Westphalia (Oberverwaltungsgericht Nordrhein-Westfalen), order of 28 April 2006 – 13 A 2495/03; Federal Administrative Court (Bundesverwaltungsgericht), order of 25 June 2007 – 3 B 82.06; Higher Regional Court of Karlsruhe (Oberlandesgericht Karlsruhe), judgment of 17 February 2012 – 4 U 197/11.
• Higher Administrative Court of North Rhine-Westphalia (Oberverwaltungsgericht Nordrhein-Westfalen), judgment of 18 April 2013 – 13 A 1210/11; Federal Administrative Court (Bundesverwaltungsgericht), order of 17 January 2014 – 3 B 48.13; Higher Administrative Court of North Rhine-Westphalia, order of 17 May 2017 – 13 A 168/16.
• German Dental Association (Bundeszahnärztekammer), Kommentar zur Musterberufsordnung (commentary on the model professional code of conduct), 5th edition 2024, section 1, margin nos. 16–17. Zeller, Beck-Broichsitter, Fehn: Botulinumtoxin in der Bruxismustherapie, zm 22/2022.
• German Medical Association (Bundesärztekammer) and National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung): Persönliche Leistungserbringung (personal provision of services), 29 August 2008.
• Administrative Court of Düsseldorf (Verwaltungsgericht Düsseldorf), order of 12 June 2025 – 20 L 1075/25. Baden-Württemberg State Health Office (Landesgesundheitsamt Baden-Württemberg), notice of 28 August 2019. Implementing Regulation (EU) 2022/2346, Annex IV.
• Federal Court of Justice (Bundesgerichtshof), judgment of 31 July 2025 – I ZR 170/24.
• Higher Regional Court of Hamm (Oberlandesgericht Hamm), judgment of 12 May 2026 – 4 UKl 3/25. Higher Regional Court of Frankfurt am Main (Oberlandesgericht Frankfurt am Main) – 6 U 362/24 (notice from the Wettbewerbszentrale of 19 February 2026; not final).
• Austria: Federal Act on the Performance of Aesthetic Treatments and Operations (ÄsthOpG), section 4. Switzerland: Swissmedic information sheet “Injizierbare Produkte zur Faltenbehandlung” (injectable products for wrinkle treatment), version 4.0 of 19 June 2026.

As at: 12 October 2026. This article provides an overview and is not a substitute for legal advice. In case of doubt, the competent chamber of physicians or dentists and a specialist lawyer for medical law can provide information.