By Patrick O’Brien, General Counsel, American Med Spa Association

On September 23, 2025, the Alabama Board of Medical Examiners (BME) issued a notice reaffirming the requirements to perform cosmetic botulinum toxin injections, such as Botox. This notice was issued in response to the Alabama Board of Nursing issuing a declaratory ruling that contradicted these existing requirements. This declaratory ruling is not yet posted on the Board of Nursing’s website, but, according to the BME’s notice, the ruling appeared to authorize registered nurses (RNs) to administer botulinum toxin for cosmetic purposes. This runs contrary to the current BME rules.

To review: Alabama is the most restrictive state when it comes to cosmetic injections. For many years, only a licensed physician could perform neuromodulator injections, and they were unable to delegate the treatments to anyone else. Beginning last year, the BME, together with the Joint Committee for Advanced Practice Nursing and the Physician Assistant Advisory Committee, approved a new rule that would allow nurse practitioners (NPs) and physician assistants (PAs) to perform cosmetic injections once they have a protocol approved by the board. There are a number of other requirements and limitations, but, generally speaking, this rule would allow PAs and NPs to begin providing these services. The BME provides an application with instructions for those want to apply—see the PDF at this link. Importantly, these protocols do not allow the procedures to be delegated to anyone else.

It is important to remember that even without this clarification by the BME, it is typically not a good idea to rely too heavily on declaratory statements or rulings. Declaratory rulings are only decisions by the issuing body about the specific circumstances of the person requesting the ruling. While they can sometimes provide guidance on how a board may view a similar situation, they do not provide any general authority for others to act. This is similar to the situation in Florida, discussed in this article, where, after many years of declaratory statements denying RNs the backing to perform cosmetic injections, the Florida Board of Nursing began issuing statements approving the RNs. While that may indicate an overall change in the board’s stance, the declaratory statements can only be relied upon by the person who requested them.  

In the BME’s notice, it stresses that although the declaratory ruling may say that one RN is okay to inject with the nursing board, it does not authorize any physicians to delegate the treatment to them. A physician attempting to delegate a cosmetic injection to an RN or anyone else would be in violation of Alabama’s standard of care and open the physician up to professional discipline. Currently, only a physician or a PA or NP who has an approved protocol can provide cosmetic neuromodulator injections in Alabama.

AmSpa monitors the latest med spa legislation and board rules in your state to keep you informed and help you stay compliant. Visit the med spa legal updates page for news from this year's legislative session, or book your annual consultation with national health care law firm ByrdAdatto for a personalized look at your practice compliance.