Clinical Studies Combined v1.0
Beauty Versus Medicine: The Nonphysician Practice of
Dermatologic Surgery
HaRolo J. Bnorl MD,* Rov G. GpRoNEuus, MD,t eNo perRrcre K. FAR
s, l,tot
*Department of Dermatology, Emory lJniuersity Medical School, Atlanta, Georgia,rDepartment of Dermatology,
I:Iew York Uniuersity School of Medicine and Laser and Skin Surgery Center of New York, New York,
iDepartment of Dermatology, Twlane [.Jniuersity School of Medicine, llew Orleans, Louisiana
BACKGRoUND. This investigation was initiated because of a
growing concern by the American Society for Dermatologic
Surgery about the proliferation of nonphysicians practicing
medicine and its impact on public health, safety, and welfare.
oBJECTIVE. Prompted by an alarming rise in anecdotal reports
among dermatologic surgeons, the study sought to determine
whether there was a significant increase in the number of
patients seeking co
ective treatment due to complications from
laser and light-based hair removal, subsurface lase
light
ejuvenation techniques, chemical peels, microderma
asion,
injectables, and other cosmetic medical/surgical procedures
performed by nonphysicians without adequate training o
supervision.
METHoDS. A survey of 2,400 American Society for Dermato-
logic Surgery members in July 2001 and in-depth phone
interviews with eight patients who experienced complications
from nonphysicians performing cosmetic dermatologic surgery
procedures were conducted.
RESULTS. Survey data and qualitative research results attrib-
uted patient complications primarily to "nonphysician opera-
tors" such as cosmetic technicians, estheticians, and employees
of medical/dental professionals who performed various invasive
medical procedures outside of their scope of training or with
inadequate or no physician supervision.
CoNCLUSIoN. The results underscore the need for improved
awareness, legislation, and enforcement regarding the nonphy-
sician practice of medicine, along with further study o{ this
issue.
H. J. BRODY, MD, R. G. GERONEMUS, MD, AND P. K. FARRIS, MD HAVE INDICATED NO SIGNIF/CANTINTEREST
WITH CO MMERCI AL S UPPORTERS.
AN INCREASE in complications of cosmetic surgery
procedures, often the focus of lay media "ho
o
stories," is in fact reported by physicians according to
a recent survey conducted by the American Society fo
Dermatologic Surgery (ASDS). The survey indicates
that the prevalence of the nonphysician practice of
medicine, particularly in rhe field of cosmeric derma-
tologic surgery, points to a budding public safety
hazard of a possibly alarming incidence of patient
complications. Numerous medical treatments that
traditionally present a low-risk profile are now being
cited as the cause of scars, burns, and permanent
hypopigmentation. Interviews with patients who were
harmed or disfigured by nonphysicians show unsafe
and unscrupulous practices associated with this evol-
ving method of healthcare delivery.
There are four factors in today's medical/health
environment that play a crucial role in the nonphysi-
cian practice of cosmetic surgery: (1) increased use and
acceptance of nonphysician cliniciu.rsl INPCs) in the
Address co
espondence and reprint requests to: Harold J. BrodS MD,
.550 Peachtree Street, N.E., Suite 1135, Atlanta, GA 30308, or e-mail:
hail eyand
XXXXXXXXXX.
(q 2003 by the American Society t'or Dermntologic Surgery, lnc, . published
ISSN: XXXXXXXXXX/02/$15.A0/0 . Dermatol Surg 2003;29:319 324
healthcare areta) (2) the variability of uniform state
laws defining the practice of medicine, (3) the blu
etween medical procedures and beauty treatments,
and'(4) the emergence of hy
id "mediial spas" anj
"retail clinics."
This multifactorial phenomenon has created a new
de facto
eed of nonphysicians: "nonphysician
operators" (NPOs). NPOs are defined in this study as
providers of cosmetic dermatologic treatments, most
frequently outside the medical seting, who typically
do not have the necessary medical training and
qualifications to diagnose the condition, perform the
procedure, or address adequately complications when
they arise. As a result, NPOs presenr potenrial liability
for the supervising physician or medical director, and
their clinical role in the practice of medicine should be
more clearly defined, enforced, and monitored by state
egulatory agencies and medical boards.
Scope of the Study
In July 2001, the ASDS conducted a survey of irs
2,400 members to document the number of dermato-
logic surgeons who in the preceding 12 months had
y Blaclonell Publishing, Inc.
320 BRODY ET AL.: BEAUTY VERSUS MEDICINE
treated patient complications due to the nonphysician
practice of medicine. The one-page questionnaire
focused on the frequency of patients seeking consulta-
tion for co
ective treatments and the clinical nature of
their complications. The overall response rate was
20"/o, with 480 dermatologic surgeons responding.
Forty-five percent of the respondents reported an
increase in patient complications by nonphysicians
(Figure 1).2
In addition to survey data, in-depth interviews were
conducted by phone with eight patients who experi-
enced complications from nonphysicians performing
cosmetic dermatologic surgery procedures, including
laserilight based hair removal, chemical peeling, tattoo
emoval, and microderma
asion treatment. The
subjects of the phone interviews were provided by
ASDS members in response to a request for patient
testimonials. Specific characteristics related to treat-
ment, provider, setting, adverse effects, follow-up care,
and state guidelines were collected and are summar-
ized in Table 1.
An examination of state laws and medical practice
acts was conducted. Position statements and guidelines
adopted by state medical boards regarding the use of
lase
light-based devices, chemical peels, and othe
cosmetic techniques by nonphysicians were reviewed
to better identify the clinical scope of NPOs and the
esponsibilities of a supervising physician.3-s
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Dermatol Surg 29:4:April 2003
lncidence of Complications
The ASDS member survey results (^1: 480) indicate
that laser and light-based hair removal procedures by
nonphysicians accounted for the majority of reported
complications with 111 dermatologic surgeons noting
such adverse effects as second and third-degree burns,
permanent nerve damage, and sca
ing. Ninety-five
espondents treated cases of complications experi-
enced by rosacea patients with misdiagnosis and
delayed treatment of rosacea cited as most common.
Ninety ASDS members reported patient complications
from chemical peeling procedures performed by
nonphysicians, and 78 treated complications afte
microderma
asion techniques. Forty-four dermatolo-
gic surgeons provided co
ective care for complica-
tions from the nonphysician performance of
nonablative skin rejuvenation procedures, including
intense pulsed light and laser devices. The remaining
62 respondents reported multiple and varied compli-
cations from treatments such as sclerotherapy, botuli-
num toxin therapy, inappropriate skin cancer and acne
therapy, and misdiagnosis of actinic keratoses, eczema)
and fungal disorders, among others. Because of the
small sample size, these results are considered pre-
liminary and suggest the need for additional and
ongoing tracking and monitoring.
In six of the eight cases profiled during telephone
interviews, an NPO such as a beauty salon owner,
technician, or cosmetologist administered treatment;
the other case involved a registered nurse, and
one patient was unable to identify the provider's
credentials (oral communication, December 10,
2002).
Five patients suffered complications from lase
light-based hair removal treatment, including blisters,
urns, hyperpigmentation, infection, and sca
ing on
the legs, arms, and face. The three remaining patients
experienced complications from NPO-administered
microderma
asion, chemical peeling, and tattoo
emoval. Second- and third-degree burns occu
ed
from a 35% trichloroacetic acid peel applied to the
patient's legs by an unsupervised product sales
epresentative, resulting in permanent nerve damage,
permanent scars, and hypopigmentation. After an
aggressive, deep microderma
asion performed at a
skincare clinic by a visiting salon owner, anothe
patient suffered a three-inch round skin a
asion on
her right cheek and multiple a
asions scattered on the
other side of her face. For tattoo removal on the ankle,
an esthetician in a northern California spa applied
glycolic acid after skin ablation with a pumice stone.
This third patient experienced a fever of 1,02.5 F and
an infected ankle for 10 days before a physician at an
urgent care facility prescribed antibiotics and told he
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Figure XXXXXXXXXXASDS member survey of patient complications caused
y NPO of medicine. The data were complied in July and were based
on a survey of 2,400 ASDS members. Nearly 45o/o of the respondents
eported an increase in patient complications treated during the past
year.
Dermatol Surg 29:4:April 2003
Table 1. Patient Complications
BRODY ET AL.: BEAUTY VERSUS MEDICINE 321
Case Provider Treatment Complication -State Environment Comments
Cosmetologist
Nurse
Electrologist
Product sales
Tech n icia n
Not sure of
Salon owne
Esthetician
Laser hair removal
on legs
Laser hair removal
on upper lip
Laser hair removal
on arms
Chemical peel
on legs
Burns and scars
Blistering and
hypertrophic scars
Burns, infections and
skin discoloration
Second- and 3rd- degree
urns and nerve damage
GA MD supervision
Cosmetic expert who theoretically was
on staff turned out to be a dentist.
Nurses who administered treatment
were "still taking classes" on how to
operate laser equipment.
Suffered burns the size of a quarter.
Refe
ed by phone to an obstetrician
when patient cailed about wound care
for her complications.
Doctor's office with sales representative
and esthetician has permanent scars and
hypopigmentation More than 1 yea
later, patrent has dark, blotchy scars
where her skin peeled off that are
worse than the ones she originally
wanted removed after treatment fo
Grave's drsease.
When patient complained to the spa
manager about her complications, the
patient was reminded that she had
signed a consent form regarding risks
such as sca
ing and essentially sent on
her way without any wound care.
Patient of lndian ethnicity practitioner's
credentials on-site physician with
Type lV Skin Type.
Could have been permanently sca
ed
had she not gone to dermatologist fo
wound care immediately after treatment
Esthetician dissuaded patient from lase
treatment in favor of her own method.
When patient complained of intense
pain and swollen and infected ankle,
esthetician reassured her this was
normal. After 'l 0 days of high fever,
patient was told by urgent care docto
that had she waited any longer she
would have lost her foot.
CA
Dental/medical spa
Skin care clinic
Home-based office
Laser hair removal
on underarms
Laser hair removal
on neck
Micro-derma
asion
on face
Tattoo removal
on ankle
Burns, scars and
hypo-pig mentation
First- and second-degree
u rns
Multiple facial a
asions
IL
Fever and infected ankle CA
NY Spa/salon
NY
"Laser center"
with no
Salon
Spa
if she had waited much longer, he would have needed
to amputate her foot.
lnadequate Supervision
The in-depth interviews also revealed that the majority
of eight patient treatrients were performed in salons,
spas, and nonmedical skin clinics. In one case of lase
hair removal, the procedure was rendered at an office
in the home of an NPO. In all but one incident, the
NPOs were acting independently and without direct
supervision at the time of the procedure. A dentist
overseeing a cosmetologist perform laser hair removal
constituted the only case in which the patient was
aware of direct supervision (oral communication,
August 14,2002)