The
changing face of skin care
Lines blurring between dermatology and
cosmetology
In a classic episode of the sitcom Seinfeld, Jerry dates a dermatologist, who says she's "saving lives" all day by treating skin diseases. Jerry is skeptical, and his sidekick George squawks: "Saving lives? She's one step away from working at the Clinique counter."
Think about
that before you rush off to get your forehead smoothed or your skin freshened
for the holidays. George's assessment may be a little harsh, but there's no
denying that the line between dermatology — the medical specialty devoted to
skin disorders and diseases — and cosmetology — the practice of improving
a person's appearance — is becoming increasingly blurred.
Indeed, the term "cosmeceutical" — a product marketed as a
cosmetic that purportedly has biologically active ingredients that affect the
user — has sprung up to define a broad gray area where the practice of
medicine and the pursuit of vanity meet.
Companies heavily invested
A variety of factors are behind the rise of cosmeceuticals: the aging of
the baby boom generation; increasingly effective alternatives to plastic
surgery, such as Allergan's Botox; and the financial disincentives of managed
care. Add them all up, and cosmeceuticals comes to a booming business that has
implications far beyond the promise of diminished crow's feet and less-visible
laugh lines.
From 2003 to 2004, sales of skin-care cosmeceuticals in the U.S. are expected
to grow by 7.3 percent, to $6.4 billion, according to consumer industry
tracker Packaged Facts. Major cosmetic companies — including Estee Lauder,
Avon, L'Oreal, and Revlon — are already heavily invested in such products
and will continue to be.
So far, relatively few drugmakers, besides Allergan and Johnson & Johnson,
with its Vitamin A-based drugs, are in the business. That may change, though.
The success of Botox, which was a $564 million product in 2003, and the aging
of youth-obsessed baby boomers haven't been lost on the drug industry. Pfizer,
for one, bought a company called Anaderm in 1996 to focus specifically on
cosmeceuticals.
Elevated aestheticians
Certainly, the business of improving appearance by medical means is vast
and is growing in many directions. Along with cosmeceuticals, a wide range of
treatments are available in doctors' offices. Chemical peels, laser
treatments, microdermabrasion, which were once primarily the purview of spas
and beauty clinics, are now common offerings at many dermatologists' offices.
Doctors are opening their own spas, lending their names to various product
lines, and writing books detailing methods that allegedly keep skin youthful.
About half of all dermatologists sell cosmetic products in their offices,
estimates Howard Maibach, professor of dermatology at the University of
California, San Francisco.
As a result, patients increasingly see dermatologists as having the skills and
tools to reverse or halt the aging process — and many doctors are more than
happy to serve as elevated aestheticians. The reality is that doctors in the
profession are "tour guides" to patients traversing a confusing
world of products and services (Botox, collagen, lasers, and peels) promising
youth, says Richard Glogau, clinical professor of dermatology at University of
California, San Francisco. (Glogau consults for several cosmeceutical makers.)
Plenty of dermatologists view selling cosmeceuticals as good medical practice.
"What we love about dispensing [these products] is we really know what
patients are using," says Patricia Farris, a dermatologist based in New
Orleans and clinical assistant professor at Tulane University.
A blemished reputation?
There's no denying that they're good business, too. She says such products are
the beginning of a "step-up process" to prescription drugs or
procedures like Botox injections and laser treatments, which is where the
biggest dollars are. "You don't start with the big guns," says
Farris. (Farris consults for a number of cosmetic companies.)
This emphasis on the aesthetic rather than the medical has some in the field
concerned. "Cosmetic dermatology is really injuring the reputation of
dermatology," says Eileen Ringel, a dermatologist in Maine who is also on
the Food & Drug Administration's advisory committee for dermatology.
"People come to me and think I'm a cosmetologist, and they don't know the
difference. That's our fault as dermatologists." (Ringel doesn't perform
cosmetic dermatology services of any kind.)
Dermatologists' reputation may not be all that's suffering. As these
practitioners spend more time addressing cosmetic complaints, they have less
time to treat patients with skin diseases, including potentially fatal skin
cancers. The average wait time to see a dermatologist in major cities around
the country is 24.3 days -- the longest among high-demand medical specialties
including obstetrics and gynecology and cardiology -- according to a 2004
survey by physician staffing firm Merritt, Hawkins & Associates.
'One-dimensional'
According to data from the American Academy of Dermatology's 2002 practice
profile survey, 90 percent of dermatologists interviewed reported a need for
more medical or general dermatologists in their local area, while only 13
percent cited a need for more cosmetic dermatologists. "A severe shortage
of dermatologists threatens patients' access to care and is likely to further
increase the amount of medical and surgical skin care provided by
nondermatologists," the study's authors wrote.
Though dermatology has become one of the most sought-after specialties among
medical students, some fear that the field's dynamism is faltering. Funding
from universities and industry alike for "basic science and research [on]
important diseases is shunted to cosmetics," says Ringel. New York-based
dermatologist A. Bernard Ackerman agrees: "Instead of being multifaceted
and fascinating, it is one-dimensional." (Ackerman doesn't perform
cosmetic dermatology.)
Sheldon Pinnell, professor emeritus at Duke University, disagrees. "I'm
bullish about the profession from a number of points of view," says
Pinnell. "[We're researching] everything from conditions that are
life-threatening to ways of protecting skin that improve the cosmetic nature
of skin." Advances in technology could soon spur the FDA and professional
societies like the American Academy of Dermatology to make more rigorous
demands of skin science and its practitioners, critics say. Both are now
largely absent from the debate. (Pinnell is a consultant to a line of products
called SkinCeuticals.)
Among consumers, the popularity of cosmeceuticals will continue to rise as
long as improving physical appearance remains a top social priority. The
question is: What will be the medical and scientific community's role in
shaping this fast-rising field?