Procedural dermatology and its unmet need

Milestones

The beginning of procedural dermatology perhaps predates recorded history.³ Skilled dermatologic surgeons extensively use flaps and reconstructions, and this use dates back to the time of Sushruta, an Indian pioneer in dermatologic and plastic surgery.⁴ Modern “procedural dermatology” formally started around half a century ago when various like-minded dermatologists practicing different procedural interventions collaborated and started a separate publication focusing on this sub-division of dermatology.⁵ Prof. Lawrence Field is considered the father of modern dermatologic surgery.⁶ In India, two organisations dedicated to the field of dermatologic surgery, namely, the Association of Dermatological Surgeons of India and the Indian Academy of Cutaneous Surgeons, were launched in 1993 in Manipal and Kolkata, respectively. They were later merged to form the Association of Cutaneous Surgeons of India.⁷

Dermatologists have been pioneers in chemical peeling,⁸ cryosurgery,⁹ vitiligo surgeries,¹⁰ hair transplantation surgeries,¹¹ soft tissue augmentation and rejuvenation procedures. A large number of aesthetic or cosmetic procedures, like hair transplantation, were started first by dermatologists and later adopted by others.⁶ Although not primarily discovered by dermatologists, dermatologists perform the maximum number of botulinum toxin injections,¹² skin cancer excisions including Mohs’ surgery,¹³ liposuction¹⁴ and electrosurgery¹⁵ [Table 2]. In the USA, the volume of reconstructive surgical procedures by dermatologists exceeds that of any other specialty, including plastic surgery.¹⁶ Not only do dermatologists perform more excisions for skin cancers, but they also do so better and more adequately than other practitioners.¹⁷ Dermatology probably utilises the highest numbers of lasers, light sources and energy-based devices amongst the various medical specialties.

Shift in models

Earlier, a conservative mindset was supported by limited availability and experience of procedural modalities, hence the general hierarchical approach of dermatologists was to first try medical interventions while procedures played a supplementary role and often required referral to surgical disciplines [Figure 1a]. Many diseases were considered untreatable as they were not amenable to any medical therapy, and patients were counselled without attempting any procedure in line with the ‘first do no harm’ principle. For diseases like early-stage androgenetic alopecia, melasma and other pigmentary disorders, a hierarchical model is still valid, that is, they are generally treated first with medical treatment and if medical treatment fails, procedures can be tried.^18,19

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Figure 1a

Models of dermato-therapeutics: (a) Conventional hierarchical model

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However, with the established efficacy, safety and wide availability of a variety of procedures, the hierarchical model has given way to complementary [Figure 1b] and combination models [Figure 1c]. Many diseases previously considered untreatable are now offered procedures as the first-line modality for management (e.g., acrochordons, vascular malformations, tattoos, epidermal, pigmented and vascular nevi, mucoceles, cysts and malignant tumours).^20-22 Procedures are also indicated to tackle residual changes following successful medical management of certain conditions (e.g., leprosy, panniculitis, linear morphea and infantile haemangiomas).^23-25 Certain conditions involve utilising a combination of medical and physical modalities initially itself (e.g., keloids, acne scars and chromoblastomycosis).^26,27 Hence, medical and procedural dermatology should now be considered complementary to each other.

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Figure 1b

Models of dermato-therapeutics: (b) Complementary model

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Figure 1c

Models of dermato-therapeutics: (c) Combination model

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The division of management of diseases into these models is not clear-cut or uniformly accepted. The choice of order of utilising these modalities is also subjective and based on physician preference. Often clear guidelines do not exist and even if they do, patient preference is also a determining factor, examples being the choice of utilising medical treatment versus a surgical modality as the first-line treatment for segmental vitiligo. Similarly, for many conditions, the levels of the traditional hierarchical approach are also in the process of rearrangement, the classic example being the utility of early surgical intervention versus prolonged antibiotic therapy in moderate-to-severe hidradenitis suppurativa.^28,29 The decision of whether to use a procedure as the first-line or medical treatment or combination should be need-, cost- and evidence-based.

Current demand

The demand for procedural dermatology is growing exponentially. A total of 11.3 million surgical and 13.6 million non-surgical procedures were performed worldwide in 2019, 3.8% and 1.6% of which respectively were done in India. India ranked fourth amongst all included countries in liposuction, sixth in hair removal and eighth in facial rejuvenation.³⁰ Hair transplantation,^31,32 botulinum toxin injections³³ and medical aesthetic device-based procedures³⁴ have either shown or are predicted to show, a double-digit annual growth rate in India and the world. In the USA, there has been an exponential increase in body sculpting procedures, laser/light and energy-based treatments, fillers, wrinkle-relaxing procedures and procedures to remove non-melanoma skin lesions.³⁵

This rise in demand has been consistent despite the global financial crisis of 2007-2008 and the COVID-19 pandemic.^36,37 The USA had a 54% increase in botulinum toxin injections and a 75% increase in filler treatments in 2020 compared to 2019.³⁸ In 2020, while conventional surgical procedures dropped by 10%, there was a 5% rise in minimally invasive cosmetic procedures worldwide. India accounted for 5% of these procedures, with hair removal and facial rejuvenation being the most common.³⁹

The social factors contributing to this rapid rise in the patient pool include an enhanced consciousness about looks, a direct perceived correlation between attractiveness and ‘success’ at work and in relationships, minimal downtime of the newer procedures, social-media-driven goals of appearance, the background lack of regulatory controls over such procedures and increasing disposable incomes in contrast to earlier economic frugality.^40-42

Training and research opportunities

There are many fellowships in procedural dermatology in India and the rest of the world, including the USA, UK, Europe, Australia, Middle East and South-East Asia. These range from six months to two years in duration. The American Society for Dermatologic Surgery has certified fellowship programmes in cosmetic dermatologic surgery and procedural dermatology. The latter has 47 participating programmes offering 55 positions annually, which are highly contested.⁴³ The American Society for Dermatologic Surgery has four other internationally recognised procedural dermatology training programmes in South Africa, Romania, Pakistan and the Netherlands,⁴⁴ and programmes for international graduates. The International Traveling Mentorship Program was established in 2010 through the Lawrence Field, MD, International Dermatologic Surgery Education Exchange Fund to enhance the surgical skills of dermatologists and to facilitate the exchange knowledge between international counterparts.⁴⁵ Through the International Traveling Mentorship Program, the American Society for Dermatologic Surgery and Dermatologic and Aesthetic Surgery International League assist dermatologic surgeons to visit a host institution in another country or host a dermatologic surgeon from another country for a defined period of training. The list of approved mentors/hosts under the International Traveling Mentorship Program is mentioned in Table 3. The UK’s British Society for Dermatological Surgery offers post-residency fellowships in Mohs and advanced dermatological surgery at eight centres.⁴⁶ The Netherlands also has a fellowship training programme,⁴⁷ and Australia offers multiple 1-2 years of procedural dermatology training programmes.⁴⁸

Not many formal training opportunities in this sub-division of dermatology are available in India and dermatologists depend on short-term training programmes and observerships, and live and cadaveric workshops in conferences, which cannot be considered as adequate training for a specialty involving invasive procedures. Under the Indian Association of Dermatologists, Venereologists and Leprologists, fellowship programmes in procedural or cosmetic dermatology for 1-3 months are offered every year and receive a large number of applications. The Association of Cutaneous Surgeons of India offers observerships in dermatologic surgery and aesthetics for 2-4 weeks in eight cities biannually for its members.⁴⁹ The universities/institutes offering fellowships/observerships in dermatologic surgery or aesthetics are also summarised in Table 3.^45,49,73-93 Qualified dermatologists from India and other countries are eligible for the international fellowships and training programmes mentioned in Table 3.

The extent of the unmet need

There is a great unmet need for procedural dermatologists globally. The extent of unmet need for conventional dermatologic surgery can be gauged by the data from the waiting list of a tertiary centre that performs these procedures frequently and at a low cost. Five minor procedural dermatology operation theatres run five days a week at All India Institute of Medical Sciences, New Delhi, India, with an average of 86 conventional dermatological surgeries, 372 minimally invasive procedures, 402 device-based interventions and 287 skin biopsies carried out per month in the year 2019. In a retrospective analysis of records (authors’ unpublished data), the waiting period was 8.5 months for various lasers, 3.5 months for vitiligo surgeries, five months for fat grafting, three months for scar revisions and 1.75 months for radiofrequency ablation or sclerotherapy for vascular malformations. Even excision of skin cancers had a waiting period of 1.25 months despite trying to accommodate patients at the earliest possible date.

Many conventional dermatologic surgeries require specialised skills that are frequently not available even in dermatology departments of tertiary care hospitals. Procedural dermatologists or plastic surgeons are best suited to perform them, but they are frequently done by general surgeons and other specialists entailing inappropriate, incomplete or excessive revisions with poor cosmetic outcomes. In the authors’ experience, many patients with stable vitiligo and volume defects who are suitable candidates for phototherapy/cellular grafting and volume restoration surgeries respectively, are never offered these modalities despite many years of treatment in many government hospitals due to lack of availability. In developing nations where the majority of the population depends on socialised medicine and welfare systems, patients with these conditions stand virtually abandoned.

The unmet need for cosmetic procedures

The World Health Organization defines Health as “a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity.”⁵⁰ This implies that ideally, to be healthy, patients must be free of mental and social distress which results from diseases leading to disfigurement. The lack of beauty and attractiveness is associated with a significant social disadvantage and a ‘beauty premium’.^51,52 Skin aging is also considered a disease by many experts.⁵³ Cosmetic manifestations of aging like androgenetic alopecia lead to significant distress and loss of social advantage.⁵⁴ Conventional surgeries for androgenetic alopecia, minimally invasive cosmetic procedures for reversing skin aging, and liposuction for various indications can improve quality of life and body image and reduce psychological distress and anxiety.^55-57

Despite the huge demand and benefits, the so-called ‘cosmetic’ minimally invasive procedures are frowned upon in academic settings. In the authors’ experience, Indian tertiary government hospitals have limited expertise in cosmetic procedures for aging and rejuvenation, and only a few minimally invasive procedures to treat benign growths or symptomatic diseases are carried out. The alleviation of impact on quality of life due to aging is not considered a priority in resource-limited settings. The majority of these procedures are uninsured and are done in private set-ups for the affording segment of the population. Even if people with limited economic means have a high willingness to pay for these procedures, their aesthetic and perceived social concerns are paternalistically disregarded by many dermatologists. This perpetuates social disparities due to economic disparities. Aesthetic socialism dictates that everyone should have the opportunity to enhance or restore beauty where it is lacking or when it is lost due to disease, trauma or aging.⁵¹

Limited training

Due to the limited number of specialists and centres providing training in various conventional surgeries and procedures, there is a large unmet need for training opportunities.

Some medical institutions in India do train residents in procedural dermatology, but the training needs to be standardised, formalised and modularised, and research be included as a component of the training. In an online survey of 103 dermatologists trained in India and practicing across the world, 59% felt that greater exposure to cosmetic and procedural dermatology was required to improve the training programme (authors’ unpublished data).

There are significant differences between the dermatology residency training programmes in India and internationally. The Indian residency programme is three years long, akin to other specialties, whereas, the length of dermatology residency is 3-4 years in the USA,⁵⁸ four years in the UK⁵⁹ and Australia⁶⁰ and five years in Ireland.⁶¹ Procedural dermatology training in the US incorporates dedicated hours in the first, second and third years of residency.⁶² The residents need to maintain a detailed logbook or portfolio for supervised and independently done procedures in these countries.^59,61 A minimum number for each procedure is required to be eligible for the final qualification.⁶¹ Third-year dermatology residents in the US are expected to perform procedures independently and also train other trainee doctors in these techniques.⁶² In India, this level of autonomy and independence is hard to achieve due to limited training, but efforts are underway. Recently All India Institute of Medical Sciences, New Delhi incorporated live supervised procedures on patients by the examinees as part of the final MD (Dermatology and Venereology) practical exam. This can be replicated in other institutions in a phased manner as the training level improves. Most large institutions in the USA have about one-third of their 25-30 board-certified faculty focusing nearly entirely on procedural dermatology,⁶³ with dermatologic surgery sessions happening both pre-noon and afternoon five days a week.

The unmet need for research

There is a significant lack of evidence-based guidelines and consensus for the procedural treatment of various dermatological diseases. For example, while surgical excision is the definitive and potentially curative treatment for hidradenitis suppurativa, there is no definite recommendation on surgical modalities in the Cochrane review of its treatment, as good-quality controlled studies are lacking.⁶⁴ The same is the case for procedural management of post-acne scars.⁶⁵ It is difficult to perform controlled studies in surgical procedures, and even well-conducted studies are downgraded when compiling evidence due to the lack of a sham surgery control. Individuals and centres treat patients based on individual preference, training and availability.⁶⁶ Similarly, there is a lack of standardisation of platelet-rich plasma protocols for various indications. Many procedures have different risk-benefit ratios or procedural parameters in the skin of colour, while most published research originates in fairer skin types.⁶⁵ Amongst the public as well as in academic circles, there is a perception that aesthetic procedures are more commerce-driven than based on sound scientific research and principles. This is because high-quality research is lacking for many cosmetic procedures and devices.

Pioneer tertiary research centres must encourage research studies in procedural dermatology to generate more evidence about the benefit of various procedures and combinations, their adaptability to low resource settings and the standardisation of various techniques. This will encourage more dermatologists to practice procedures and more medical institutions and national boards to add them to their residency training curriculum.

Unqualified practitioners and complications

The rapid rise in demand for procedural dermatology has not been paralleled with a proportionate increase in trained personnel or the establishment of treatment guidelines or quality control methods. There are no National Medical Commission of India guidelines on minimal qualifications required to perform these procedures, unlike in some other countries, like Singapore.⁴² This has resulted in unsupervised procedures done by untrained and unqualified practitioners often resulting in serious potential consequences. Many of these procedures warrant the application of sound scientific principles on a background of detailed knowledge of the anatomy and physiology of the skin; they also require standard operating protocols with emphasis on asepsis.

The majority of practitioners of medical aesthetics in China are illegal.⁶⁷ There were 28 lawsuits of severe injuries due to elective cosmetic procedures by untrained individuals from the USA in a single year (2013). Out of these 28 cases, 25% had resulted in death and a further 50% required hospitalisation.⁶⁸ The majority of laser surgery lawsuits involved non-physician operators.⁶⁹ Exhaustive data are lacking, and these figures likely represent the tip of the iceberg.⁷⁰

The Centers for Disease Control and Prevention, USA released a warning in 2008 regarding unlicensed cosmetic procedures when three women suffered acute renal failure after being injected with unlicensed liquid silicone products.⁷¹ The Singapore Medical Council subsequently introduced guidelines on the practice of aesthetic procedures for Singapore medical practitioners,⁴² and England’s Department of Health also launched a similar campaign to tackle ‘botched’ cosmetic procedures in 2019.⁷²