Dermatologic Clinics - Spa Dermatology (Vol 26 Issue 3, Elsevier, 2008)

Spa Dermatology

Preface

Neil S. Sadick, MD, FAAD, FAACS, FACP, FACPh

Guest Editor

As we expand into the 21st century, ever-increasingnumbers of dermatologists are incorporatingaesthetics into their daily practice setting. In this re-gard, a union between the aesthetic spa environmentand thepracticingdermatologist’sofficehasevolved.Taking the leapby incorporatingamedical spa intoanestablished dermatology practice can be challeng-ing; however, if accomplished successfully, it canbe associated with unprecedented professional sat-isfaction. This issue of Dermatologic Clinics outlinesthe steps necessary to accomplish these goals.

The first article of this issue outlines the stepsnecessary for incorporating a medical spa intoa dermatology practice. Following articles includeproduct, technology, employee decisions, andmarketing aspects of establishing a successfulmedical spa. These are followed by treatise outlin-ing the medical/legal considerations in the medical

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spa environment, and finally an article on futuretrends in this ever-evolving field.

A thorough understanding of the issues outlinedin this issue will allow the dermatologist who isinterested in incorporating a medical spa into theirpractice to have a successful approach to accom-plish this goal in a professional fashion, which willincrease both their satisfaction and, most impor-tantly, lead to improved patient care. Emergingtrends will enable the practitioner to keep up withthe rapid evolution of aesthetic dermatology.

Neil S. Sadick, MD, FAAD, FAACS, FACP, FACPhSadick Dermatology

911 Park Avenue, Suite 1ANew York, NY 10021, USA

E-mail address:[email protected]

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Incorporating a MedicalSpa into a Physician -RunPractice
Bruce Katz, MDa,b,*, JasonMcBean, MDa
KEYWORDS� Medispa � Medical spa � Cosmeceuticals� Branding � Benchmarking

HISTORYOF THE SPA

DeVierville1 proposed that the modern word ‘‘spa’’came into the English language via the old Walloonword, ‘‘espa,’’ which means fountain, and which inEnglish became ‘‘spaw.’’ It is difficult to pinpointthe actual origin of the first spa and spa treat-ments. The concept of the spa occurred in Europeand Asia where mineral springs and thermal mudwere used to sooth and heal varying ailments.2

During the Roman Empire 1352 public fountainsand 962 public baths were available to the citizensof Rome.3 After exercising, bathers entered the‘‘warm room’’ to acclimate to the subsequent‘‘hot room.’’ After the hot room, patrons wouldundergo an oiling massage and then plunge intoa cold pool.3 Roman soldiers sought hot baths torecuperate after long battles. The baths werereferred to as ‘‘aquae.’’ and the bathing treatmentswere known as ‘‘sanus per aquam’’ (SPA), that is,‘‘health through water.’’

After the fall of the Roman Empire, establish-ments with ‘‘hot rooms’’ disintegrated, but theconcept of the spa flourished with continued useof the major springs. Despite the Church’s disap-proval of bathing, the popularity and use of suchsprings continued. In Renaissance Italy, the ‘‘tak-ing of waters’’ was associated with gentlemanlyideal of a rustic retreat.3

In France and Germany, people frequented spasto improve medical ailments ranging from renal dis-orders and infertility to paralysis and seizure disor-ders. The Belgian town of Spa became famous for

a Juva Skin & Laser Center, 60 East 56th Street Suite 2, Nb Cosmetic Surgery & Laser Clinic, Mount Sinai Medical CL. Levy Place, New York, NY 10029, USA* Corresponding author. Juva Skin & Laser Center, 60 EaE-mail address: [email protected] (B. Katz).

Dermatol Clin 26 (2008) 307–319doi:10.1016/j.det.2008.03.0080733-8635/08/$ – see front matter ª 2008 Elsevier Inc. All

the healing powers of its mineral hot springs duringthe fourteenth century. It became a place to berestored and pampered and still exists today.

Between the sixteenth and nineteenth centuriesmany prominent figures supported the use of spawaters for treating varying ailments. Leonardo deVinci used the waters at San Pellegrino. Michelde Montaigne was relieved when the spring watersstimulated passage of a kidney stone. CharlesDarwin improved his dyspepsia with a combinationof wet sheet packing, hot air baths, and showers.3

During the eighteenth and nineteenth centuries,the use of mineral springs and the development ofhotels and boarding houses around the vicinity ofnatural springs propelled the popularity of thespa. Transplanted Europeans and North Ameri-cans learned about the healing properties ofwaters from Native Americans, and they devel-oped resorts or health retreats. Some earlyretreats such as Bedford Springs, Pennsylvania,White Sulfur Springs, West Virginia, and HotSprings, Arkansas became household namesrivaling the renowned spas of Europe.4

In the late nineteenth and early twentieth centu-ries, some of the founding fathers of dermatology,among them Ferdinand von Hebra and Louis Duhr-ing, discussed the importance in hydration andbathing for the treatment of psoriasis, ichthyosis,and pemphigus.4 Through the early twentieth cen-tury, the great spas of North American and Europewere popular destinations for the wealthy as wellas the ill, who went there to rejuvenate and recu-perate. As health care became nationalized and

ew York, NY 10022, USAenter, Mount Sinai School of Medicine, One Gustave

st 56th Street Suite 2, New York, NY 10022.


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modern medicine became more efficient, how-ever, the popularity of spas began to decline.

In the latter part of the twentieth century and con-tinuing to the present, spas re-emerged as destina-tion resorts and places for health maintenance asa complement to modern medicine. The resur-gence in the popularity of the spa sprung from thegrowing depersonalization of the modern healthcare system and from a greater emphasis on well-ness and preventive medicine. Over time, spas be-came destination locales for health maintenance.

Three major markers delineate the evolution ofthe spa industry in the United States. In the1940s Rancho La Puerta in Tecate, Mexico,focused on a return to nature and minimalismand emphasized healthy eating and fitness. Inthe 1950s the Golden Door in southern Californiadeveloped intimate, small centers of pamperingand relaxation. In 1979 the Canyon Ranch in Tuc-son, Arizona integrated health and healing into themodels pioneered by Rancho La Puerta and TheGolden Door.2 Traditional spas now are orientedtoward providing pampering and beauty treat-ments such as massages and facials and servingas relaxation centers for the wealthy. As such,the popular modern spa descends from theancient practice of bathing in hot springs andmineral waters.

Fig.1. Reception desk at Juva MediSpa.

EMERGENCE OF THEMEDICAL SPA

Despite the advances and evolution of the spa,patients and clinicians recognized the lack oftrue medical benefits from typical spa treatmentssuch as facials, body treatments, and skin careproducts. The advent of topical dermatologicagents with proven anti-aging and therapeuticeffects, as well as new technologies to treat med-ical conditions with minimal downtime paved theway for the emergence of medical spas. Theconcept of one-stop shopping for both crediblespa treatments and prescription-grade medica-tions appeals to a large segment of the population.

Medications that have demonstrated anti-agingproperties include retinoids, alpha- and beta-hydroxy acids, 5-fluorouracil, and chemical peels.Modalities that have a central role in aesthetic-based medicine include laser hair removal, vascu-lar lasers, laser photo rejuvenation, injectablefillers, chemical sclerosants, and chemical dener-vating agents. These tools are available to thewell-trained physician, require virtually no down-time, and can augment the services availablein a traditional spa dramatically. The services ofan aesthetically trained physician joined withthe pampering, wellness-oriented environmentof a spa can meet baby boomers’ demand for

credible spa treatments, provide the convenienceof one-stop shopping, and eliminate the cold,sterile, and depersonalized environment of thetraditional medical office.

What is a medical spa? First, one should definethe traditional spa. The International Spa Associa-tion defines the traditional spa as an entity devotedto enhancing overall well-being through a varietyof professional services that encourage therenewal of mind, body, and spirit.5 The medicalspa is a facility that operates under the supervisionof a licensed health care professional whoseprimary purpose is to provide comprehensivemedical and wellness care in an environment thatintegrates spa services with traditional and com-plementary and/or alternative therapies and treat-ments. The facility operates within the scope ofpractice of its staff, which can include bothaesthetic/cosmetic and prevention/wellness pro-cedures and services.

To comprehend better the full scope of a medicalspa, it is instructive to take a look inside the firstmedical spa, the Juva MediSpa. Its founder (BK)actually coined and trademarked the term ‘‘medi-spa.’’ Juva MediSpa was a traditional cosmeticdermatology practice on the Upper East Side inManhattan, New York, that employed one aesthe-tician. In this practice the author (BK) recognizedthree trends. (1) There was increased patientdemand for integrated services. (2) Traditionalspa treatments did not offer lasting skin benefits.(3) He was treating an increasing number ofpatients suffering adverse reactions caused bypoorly trained personnel at various spa locations.As a result, in 1999, the center moved to a larger,5000-square-foot facility in midtown Manhattan,and the first physician-formulated medical spatreatments were born.

At the new facility a warm and inviting environ-ment welcomes the patient as he or she entersfrom the elevator (Fig. 1). At the front desk, the

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patient is provided with an informational brochurethat details the services offered by the center andintake forms that the patient completes in thespacious reception area. Unlike a traditional spa,the patient completes a detailed demographicand medical history form. Unlike a traditionalspa, physicians are on site to assist the aestheti-cian with patient care, to answer patient questions,or to provide consultations.

Unlike a traditional medical office, the waitingarea of the Juva MediSpa is luxurious and invitingwith comfortable, cushioned chairs and additionalbrochures that provide information ranging fromthe prevention of skin cancer to the latest lasertechnology (Fig. 2). Two television monitorsprovide a visual tour of the center and mediasegments of procedures and technologies pio-neered at the Juva MediSpa. The treatment areasof the center are divided into two separate butconnected sections: one for the medispa treat-ments and the other for medical and surgicalprocedures. This arrangement allows the pamper-ing and wellness-oriented environment of the spato segue gently to the safe, efficient, professional,and confidential patient treatment area.

The popularity of the medical spa is rising asbaby boomers who have discretionary incomeaggressively seek to maintain youthful looks andsearch for preventive health care services in envi-ronments that are more pleasant than the deper-sonalized medical clinic with its emphasis ondisease. Medical spas also appeal to the growingnumber of Americans who want to combineconventional and alternative medicine in theirquest for optimal health with a holistic approach.

One example shows the benefits of this ap-proach. A patient presents for evaluation andtreatment of a large port-wine stain. She receivesa consultation regarding treatment options bya staff physician. She is informed of the risks,

Fig. 2. Reception area at Juva MediSpa.

benefits, and side effects of the treatments aswell as other alternatives. She undergoes the lasertreatment after signing a consent form and experi-ences expected postoperative purpura. In con-trast to the traditional medical office, she then isdirected to the adjacent paramedical make-upcounter located in the spa and is advised as towhich cover-up make-up would match her skintone best while camouflaging her treatment area.This one-stop shopping makes sense and iswhat the consumer demands today.

HOW THEMEDICAL SPA DIFFERSFROM THE TRADITIONAL SPA

Medical spas differ from traditional spas in severalways. At the medical spa, consumers enjoy treat-ments that have genuine medical value as well aslong-lasting aesthetic benefits. For example,depending on state law, aestheticians trained byand under the supervision of the dermatologistmay use medical devices for laser hair removaland nonablative laser rejuvenation. The aestheti-cians and physicians can consult each otherregarding patient care, and spa treatments areincorporated into medical and surgical proceduresto enhance outcomes. This collaboration con-trasts with the traditional spa where modalitiesmay be used by poorly trained technicians withoutadequate supervision. Adverse events in suchsettings have led to new legislation in certainstates restricting laser treatments to physiciansor licensed practitioners.

Because of the extensive training that dermatol-ogists, plastic surgeons, and many other physi-cians complete, treatments at medical spas suchas acid peels, lasers, botulinum toxin, and inject-able fillers can be performed safely. Sterile tech-nique always is employed when appropriate(Figs. 3 and 4), and consent forms and other

Fig. 3. Sterilized surgical instruments.

Fig. 4. Waxing station.

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appropriate documentation are kept securely onfile. Patient information is confidential, and onlydirect caretakers are permitted access. Clientsfeel more confident in the efficacy of medicallysupervised treatments and are more likely toundergo more aggressive treatments such aschemical peels and microdermabrasion with anaesthetician when a physician is on site. It isimportant to maintain the consistency of proce-dures for all treatments; that is, ancillary staffshould adhere to the same treatment protocolsfor each patient to ensure a uniform, reliable clientexperience. This concept is discussed further inthe section on management.

Patient and client documentation is anotherimportant facet of the medical spa that contrastswith practice in the traditional spa. Appropriatedocumentation is required in both the spa andmedical segments of the medical spa. As men-tioned earlier, intake forms are mandatory. Theseforms include demographic information, medicalhistory, and pertinent symptoms. Consent formsare reviewed with each patient, and no proceduresare conducted without a signed consent in thechart. Ample time is provided to answer any ques-tions patients may have.

In addition to intake and consent forms, flowsheets are created and maintained for eachpatient and for each treatment modality. In thisway, previous treatment parameters (eg, settingslaser treatments or times for chemical peel) aredocumented and can be referred to for future

treatments. These forms also may include the lotnumber for injectable fillers and chemical peels,which may assist in identifying the potential causefor adverse reactions. Finally, the flow sheets canbe used to document which provider used themodality last to identify whether laser malfunctionor adverse outcome can be attributed to humanerror. This documentation is an essential featureof the well-run medical spa that also helps educatethe staff members. These forms legitimize themedical spa and help to differentiate it fromthe traditional spa, which may not use such strictdocumentation practices (Fig. 5).

The creation of a pampering experience andattention to service is integral to the medical spaexperience. The adage ‘‘the customer is alwaysright’’ should remain in the forefront of the mindsof staff members. Attention to detail is paramount,and employees should be encouraged to takepride in their services. This attitude, although nat-ural in the spa environment, unfortunately is atodds with that of many of today’s health care pro-fessionals who are overworked, underpaid, andoften underappreciated by patients. On otherhand, patients may view these same health careprofessionals as harried, sharp, and lacking incompassion. The medical spa environment caneliminate this dichotomy.

The medical spa and traditional spa sharea serene environment. The environment of themedical spa entails both the physical setting andthe patient/client experience. Medical offices canlearn from the operation characteristically usedby traditional spas. Warmth is emphasized withlow-level lighting for common areas, soft musicon overhead speakers, and beautiful artwork.Subdued wall colors rather than the sterile beige-white should be considered. A professional con-sulting firm or spa architect should be consideredwhen developing a medical spa.

At the medical spa, clients can obtain compre-hensive skincare in a single facility that establishesthe connection between beauty and science. Thecredibility of the spa is enhanced, and the thera-peutic benefits of medically formulated agentsare passed on to the clients. This advancedprogram of aesthetic medicine can improve com-munication and relations with aestheticians andalternative medicine providers in the community.

IMPLEMENTING THEMEDICAL SPA CONCEPT

Before implementing the medical spa concept, it isimportant to understand the current trends inthe industry. Understanding these trends willhelp the practitioner tailor services appropriately,thereby meeting the needs of the targeted

Fig. 5. (A, B) Treatment modality flow sheet. (Courtesy of Juva Skin & Laser Center, New York, NY; with permission.)


population. During the 9-year period between1997 and 2006, the American Society for AestheticPlastic Surgery polled 14,000 practitioners toascertain which of the following procedureswere performed most commonly: collageninjections, hyaluronic fillers, chemical peels,

microdermabrasion, laser hair removal, and botu-linum toxin cosmetic procedures.6 Of these sixmost common nonsurgical cosmetic procedures,cosmetic procedures involving botulinum toxinrepresented more than 40% of the market share.In other words, cosmetic procedures involving

Fig. 5. (continued)

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botulinum toxin tallied more than laser hair re-moval and hyaluronic acid fillers combined. There-fore, the clinician would be well advised to providebotulinum toxin cosmetic procedures as a serviceto his patients and to train staff to answer patientinquiries about these procedures and to marketthem readily in the practice.

It also is important to conduct a continued re-view of the trends in the marketplace. The previousdiscussion about botulinum toxin demonstratesthis point. Although the use of botulinum toxin in-creased in the period between 1997 and 2006,the rate of botulinum toxin use actually decreasedby 3% toward the end of the survey, whereas the


use of hyaluronic acid filler increased by 33%. Apractitioner who did not stay current with the mar-ket trends might have missed an opportunity toserve patients appropriately, and this oversightmight have resulted in decreased profit margins.

One of the risks in implementing the medical spaconcept in a traditional medical practice is thatstaff members from varying backgrounds maynot view treatments the same way. For example,a patient presents to the spa for a facial. At theend of the facial the patient asks the staff memberabout the botulinum toxin brochure displayed inthe waiting area. Inadvertently, the staff membersays, ‘‘Oh I would never want to have a poisoninjected into my face!’’ Similarly, after a surgicalprocedure to remove a skin cancer, a patientinquires about the benefits of a chemical peel forher face. The nurse removing the sutures re-sponds, ‘‘Oh honey, you can get the same effectof a peel with many over-the-counter washes.’’One can understand how these scenarios wouldpose a problem in a medical spa practice.

Employees should be encouraged to observeclinicians perform a variety of procedures, toattend educational seminars, and to read appro-priate current literature. Clinicians should beencouraged to experience massages, to observefacials, and to listen in during make-upconsultations.

Clearly, as the practice transitions to the medi-cal spa, it is important to educate the staff aboutthe qualities of the new services available. Oneshould develop a standard operating proceduralmanual and make sure everyone reads it. A train-ing program for the staff should stress the consis-tency of services. One should create a proceduremanual and administer written and hands-on test-ing to ensure a high quality of service. Althoughmore staff may be better, it also is important toweed out underperforming members. The derma-tologist should test the services of the staffmembers personally and should employ secretshoppers to suggest improvements.

Secret shoppers or mystery shoppers are indi-viduals such as friends or family members thatthe dermatologist selects to visit the practice.While visiting the medical spa, the secret shopperevaluates every aspect of the staff and servicesfrom the moment the shopper makes the appoint-ment until he or she departs after the service. Theshopper comments on factors such as the staff’sprofessionalism and knowledge about products.The information collected by the secret shopperthen can be used to address any deficits oreducational holes that need improving. Patientquestionnaires also can be used to assess clientsatisfaction with services rendered in the medical

spa. Using regular patient questionnaires andsecret shopper reports can help maintain the qual-ity of services. Policies should be in place to keepservices consistent so that, when patients orclients have questions, the responses can beuniform and well informed. The importance ofinvesting in staff training and development cannotbe overemphasized.

Although training and testing staff members iscrucial, it is also extremely important to showthem appreciation. A holiday party or an occa-sional lunch or dinner is a simple way to rewardthe support team for work well done. One shouldmeasure patient and employee satisfaction levelsand also strive to increase one’s own productivity.

The learning curve of transitioning to a medicalspa may be steep and somewhat laborious forboth the dermatologist and the staff, but the endresult of proper education is a happier and moreteam-oriented group. When making the movefrom a medical office to a medical spa, everyoneshould convey a positive attitude about the transi-tion, especially when informing patients of theavailability of new treatments. One way to encour-age this attitude is to place mirrors at all receptionstations. This way, the receptionist may observehis or her reflection and be reminded to use sup-portive body language and to smile. These adjust-ments in body language and expression can beperceived over the telephone as well as in theoffice.

MARKETING THE PRACTICE

Marketing is an important way to inform patientsand the public about the new services a medicalspa provides. One should plan to allocate about2% to 5% of revenues as a marketing budget topromote the medical spa. A reputable public rela-tions firm can identify the appropriate media toreach the targeted demographic group based onage, socioeconomic description, geographic loca-tion, and other factors.

Branding is the first step in marketing a business.Branding is a concept that may be foreign to manyphysicians, but branding has been shown to im-prove recognition of services and products. Forexample, in 1999, Aflac was a zero-profile com-pany selling supplemental health insurance in theworkplace. A television advertisement in 2000showed two people sitting on a park bench tryingto remember the insurer’s name. A duck remindsthem over and over again by quacking the name‘‘Aflac’’ in the voice of comedian Gilbert Gottfried.After the introduction of the advertisement, thecompany enjoyed 90% brand awareness, a rateunheard of in its market.7 Just as branding was

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used in the television commercial, branding canhelp the new medical spa create visibility and rec-ognition. Most importantly, it conveys the positiveexperience a patient or client can expect at thespa. Branding of a medical spa starts with thecreation of a logo, which should be simple butmemorable. The logo helps personalize the prod-uct line as well as all aspects of the spa. Thelogo should be put on everything and everywhere:printed material, robes, cups, pens, and otheritems used in the facility (Fig. 6).

Other important marketing concepts includecomprehensive brochures, monthly lectures,a quarterly newsletter, discounts for bringing orreferring a friend, and gift certificates. A custom-ized brochure should describe the services avail-able, office policies, and physician profiles(Fig. 7). The design should be updatable easily toinclude the latest procedures.

Monthly lectures are a great way to bring newpatients into the center. At Juva Skin & Laser Cen-ter, the waiting area is equipped with a projectionscreen that drops from the ceiling for presenta-tions and visual aids. The lecture series serveseveral functions. (1) They get people in the doorand introduce them to the clinic and spa. (2)They inform and educate the public about theservices offered. (3) They allow the creation ofa database containing the contact information ofprospective clients.

Perhaps the most powerful referral source fora center is the happy, satisfied patient. Happy pa-tients also are the least expensive way to promoteservices. A recent article suggests ways to useone’s current client base.8 An excerpt from thisarticle begins: ‘‘Mrs. Jones, thank you for yourkind words. You know I’d like to have more peoplejust like you. Would you tell some of your friendsabout us?’’ The article continues by advising one

Fig. 6. Branding: JUVA mug and robe.

to reward Mrs. Jones for the referral by sendinga note of gratitude with a gift card toward some-thing she has been buying or a procedure shewants to have done (Fig. 8). Capitalizing on theseencounters or ‘‘bring-a-friend’’ discounts areeasy ways to cultivate the existing client base.

A quarterly newsletter is a very cost-effectiveform of advertising, and suppliers’ advertisementscan reduce the cost of printing and postage(Fig. 9). These newsletters can be sent or emailedto current clients or to prospective clients whocame to a monthly lecture. One exposure usuallyis not enough. Most people forget what theyread, and they also may be slow to move. Peoplemay need up to five or six contacts before theydecide to come in for a procedure. Other market-ing strategies include a complimentary productat the initial visit.

MANAGING THEMEDICAL SPA

Revenues from a medical spa can realize a profitmargin of 20% to 30%, which can be twice thatof a traditional spa. This kind of profit margin canbe achieved only with good management, how-ever. Good management is the key to success.One should hold regular meetings with the staffand keep minutes of the proceedings. It is ex-tremely important to review the minutes from theprevious meeting to make sure that new policiesand procedures have been implemented. Oneshould be explicit in delegating tasks and shouldbe sure to state the obvious. What may seemobvious to the director may need to be explainedto members of the staff.

Regular business reports should be assembledto show important financial parameters of themedical spa. These reports include revenuesfrom procedures (broken down by providers), rev-enues from products, overhead expenses, payrollcosts, and staff productivity. Product sales shouldprovide approximately 30% to 40% of revenues,with the balance coming from services.

Benchmarking is another important practicethat should become a routine part of the business.What is benchmarking? Benchmarking is processused to ascertain the best practices that will leadto superior performance. By benchmarking onecan measure the performance of the methods,procedures, products, and services of a practiceagainst those of other practices that consistentlydistinguish themselves in the same measurementareas. Statistical comparisons include charges,revenues, expenses, and gross/net collectionpercentages. For example, most practices spenda certain percentage of their revenue on staff. Ifa practice is spending 30% of revenue on staff

Fig. 7. Customized brochure. (Courtesy of Juva Skin & Laser Center, New York, NY; with permission.)


salaries and benefits, and the industry standardspends 15% (half the amount), the leader of themedical spa should strive to achieve this targetand make adjustments where necessary to ensurethe greatest profitability. One should benchmarkthe finances of the practice frequently and makepractice planning a routine.

One should watch the business trends carefullyand investigate numbers that do not make sense.For example, several years ago at Juva Skin &Laser Center, the number of patient/client visitswas increasing, but income was dropping. What

Fig. 8. Juva MediSpa gift certificate.

could have been the reason for this? After severalweeks’ investigation, it was realized that the staffmember responsible for appointment schedulingwas scheduling extra time for new patients andprocedures, padding the schedule so that the staffmember could to leave the office earlier. This staffmember was terminated. A meeting with the restof the staff alerted them that such practices wereconsidered as sabotaging the medical spa andwould not be tolerated. To achieve optimal perfor-mance, it is important to have good informationto make good business decisions. One must

Fig. 9. Sample newsletter. (Courtesy of Juva Skin & Laser Center, New York, NY; with permission.)

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surround oneself with people one can trust, butone also should verify changes personally.

Although the example given previously could beexplained as an innocent mistake in which the staffmember did not realize how her actions mightaffect the bottom line, other more disheartening

examples of staff theft, dishonesty, and even as-sault have been reported. To enhance the safetyand security of the medical spa (for the director,for staff, and for patients), many offices use secu-rity cameras. These cameras, installed in publicareas and not in patient rooms, are a valuable


investment. They can be installed so that the areascan be viewed online even when one is not physi-cally in the office. Employees are notified of thecamera’s presence, and this knowledge helpsdiminish dramatically the impulse to take productsfrom the office. The film also serves as a possiblerecord of any criminal offenses.

As noted earlier, it is important to attract goodstaff and to train them properly. How does onedo this? Before hiring a staff member, it is crucialto have an established training program. Onemust create a training manual that details jobdescriptions. The practice manual should stressconsistency of services and responses to variousclinical and nonclinical scenarios. One shouldinvest the resources in retraining current staff andencourage the pursuit of continuing medical edu-cation credits. One should establish patient ques-tionnaires to evaluate staff performance. Oncethese building blocks are in place, one shoulduse various recruitment methods, including wordof mouth and advertisements in newspapers, med-ical journals, and perhaps on radio and television.

When an applicant is invited to visit the practice,one should make sure to include staff members(eg, the office manager, the head nurse, the patientcare coordinator, front desk manager, and evencompeting assistants) in the interviewing process.Doing so helps ascertain the ‘‘best fit’’ for the prac-tice. Also, during the interview, the intervieweeshould be asked to perform tasks relevant to thejob description. Even though applicants maydeclare they have proficiency in various programs,they sometimes exaggerate their skills. Oneshould ask the applicant to demonstrate his orher knowledge during the interview by workingwith the practice’s programs. Another method ofassessing a suitable applicant is role-playing.One can provide various scenarios and evaluatethe applicant’s responses. Factors predictive ofgood development include energy, potential, moti-vation, loyalty, and intelligence.

This discussion underscores several importantpoints. It is important (1) to investigate when busi-ness numbers do not make sense, (2) to hire theright staff and invest in staff training, and (3) toweed out the underperforming staff. Also, andperhaps most importantly, one must recognizeand embrace the role of the leader in the practice.

DISPENSING SKINCARE PRODUCTS

There are several advantages to dispensing cos-meceuticals from the medical spa. Kligman9

coined the term ‘‘cosmeutical’’ to indicate a topicalpreparation that is sold as a cosmetic buthas performance characteristics that suggest

a pharmaceutical action. This group of agentsis difficult to categorize because of the well-established practice of media hype and becausethe publication of the preparations’ true pharma-cologic actions would require reclassification ofthese agents as drugs. These factors make it diffi-cult to distinguish fact from fiction. Despite thesedifficulties, in the first half of 2002 the sales of cos-meceuticals increased by 83% while overall salesfor skincare products increased by only 1%.10

Rokhsar10 summarized the agents that show themost promise. These include vitamin C, alpha-hydroxy acids, retinoids, and growth factors. Vita-min C improves skin texture and pigmentation byacting as an antioxidant. Vitamin C is a knowncofactor in collagen synthesis and has beenshown to stimulate new collagen production. Al-pha-hydroxy acids improve dyspigmentation andfine rhytids by accelerating exfoliation, resultingin increased epidermal turnover. Growth factorsregulate fibroblasts and other mechanismsinvolved with wound healing. The end result isimproved pigment, texture, and rhytids.10

Retinoids have been shown to be the most effi-cacious of these products. Retinol is the maindietary source, transport, and storage form ofvitamin A and is found in many over-the-counterproducts. It is marketed as an anti-aging agent.In the body, retinol is converted to the biologicallyactive form, all-trans retinoic acid (tretinoin).

Several studies have confirmed the efficacy oftretinoin in improving fine lines, mottled pigmenta-tion, roughness, and laxity. Although retinol is20-fold less effective than tretinoin, and the cuta-neous concentration of tretinoin is 1000-fold lessin topically applied retinol than in topically appliedtretinoin, recent studies have shown efficacy.11

One study of 24 patients using 0.15%, 0.3%, and0.6% concentrations over a period of 6 monthsshowed histologic and clinical epidermal improve-ment in all patients using the two higher concen-trations and in 40% of those using 0.15%retinol.12 Incorporating the use of products thathave higher concentrations of retinol into the prac-tice is something to consider. The use of someform of retinoid should be a mainstay of treatmentin most patients’ skin care regimen.

In making other products available to patients,one should consider the following parameters:

1. Choose noncomedogenic formulations, espe-cially for products that will be used on theface and neck

2. Make sure products are fragrance free to avoidpossible allergic contact reactions.

3. For patients who have sensitive skin, the prod-ucts should be hypoallergenic.

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4. The ideal product should be pleasing to thepatient when applied. In other words it shouldnot feel greasy or leave a residue or film. Theproduct should be ‘‘cosmetically elegant.’’

One rationale for and advantage of dispensingproducts in the medical spa is obtaining knowl-edge about and control over the products patientsare using on their skin. In the authors’ experience,patients present to the clinic after using numerousover-the-counter or Internet-purchased products;usually these patients are using too many products(often incorrectly) that have no proven efficacyafter spending tens, hundreds, and sometimesthousands of dollars. By dispensing productsfrom a line that one has chosen personally, onecan provide the patient with efficacious, reliableproducts that are customized to meet the patient’sspecific needs. Patients who obtain products fromthe medical spa will avoid confusion from the useof other products and will obtain more compre-hensive care. Convenient one-stop shopping,minimizing irritant or contact dermatitis, andreducing issues of noncompliance are addedadvantages. Finally, repeat sales at the officeand Web site improve profit margins.

As mentioned earlier, it is important to brand theproducts. When branding the office pens, paper-work and brochures, one should consider brand-ing some or all of the topical agents. Brandingthese products adds to the medical spa’s exclu-sivity and visibility. Existing private-label linescan be used, or product formulations can bedeveloped with a cosmetic chemist. To keep theproduct line simple, one can organize it by skintype (eg, aging skin, sensitive skin, and oily skin).Products also can be organized by ingredients.With this method, one can provide comprehensivecategories such as cleansers, sunscreens, mois-turizers, eye creams, and body lotions. Key ingre-dients may include glycolic acid, antioxidants,botanicals, and alpha-lipoic acid. The productsshould be exclusive and difficult to find elsewhere.

The packaging of the products is important.Packaging provides 60% to 70% of productappeal and should be nicely styled but not flashy.The products should be presented in one location,in a highly visible area. The shelves should beopen, and testers should be available so cus-tomers can try the products. A staff person shouldbe nearby to monitor and answer questions. Allstaff, including physicians, aestheticians, nurses,and front-desk staff, should be educated abouteach product. Financial incentives may be givento all staff for selling products. One should testthe staff’s knowledge about the products andundertake a periodic analysis of sales by staff.

Some physicians may feel uncomfortableabout selling products from their practice. Sev-eral articles detail the various opinions, pro andcon, surrounding the ethical issues of physi-cian-office dispensing.13–16 Those who opposephysician dispensing claim the selling of nonpre-scription products in the office is driven solely bythe profit motive and creates an inherent conflictof interest. Proponents of physician dispensingdiscuss the convenience for the patient, im-proved compliance, and physician expertise.Although the decision to dispense is a personalone, Gormley14 suggests eight facets of ethicaldispensing:

1. The product must confer a true benefit.2. Risks, benefits, advantages, and disadvan-

tages should be discussed.3. The product must be sold at a fair price.4. There must be no misrepresentation of the

product.5. No pressure tactics should be used.6. Patients must not be encouraged to discard

existing stocks of similar products.7. Products should be sold with a replacement

guarantee.8. In the unlikely event of an adverse effect, man-

agement for the problem must be provided freeof charge.

One also should analyze the economics for thepatient and the profit for the medical spa whileavoiding pressuring the patient to buy the medicalspa’s product rather than other retail products. Toachieve this goal, the products should be pricedbelow comparable retail products. This pricingshould ameliorate the ethical dilemma of dispens-ing skincare products. In addition, one canimprove customer service and patient satisfactionby providing full refunds if a client is not completelyhappy with the product.

HEALTH ANDWELLNESS SERVICES

In addition to cosmeceuticals, several otherservices should be considered for inclusion in themedical spa. Health and wellness services area natural extension. Associating with other healthcare professionals such as nutritionists, physicaltherapists, acupuncturists, psychotherapists, andothers can provide an edge over the competition.Canyon Ranch has used this multitiered approachsuccessfully. For example, working with a regis-tered dietician who can advise clients about therelationships among food and health, fitness, andweight loss may help a liposuction patient fine-tune her posttreatment goals. Employing body


therapists who offer massage, herbal wraps, andwater treatments will underscore the importanceof the pampering environment.

The presence of a holistic physician with anorientation toward disease prevention and main-tenance of a healthy lifestyle will add to themedical spa’s cachet. This provider can be aninternist or a general or family practitioner. Oneshould select colleagues who are excellent com-municators and who value prevention anda healthy lifestyle. Patients can be referred toan acupuncturist for pain management or to a chi-ropractor for musculoskeletal issues. Patientsseeking anti-aging treatments can meet witha psychotherapist for stress reduction or smokingcessation. Those interested in liposuction or cel-lulite treatment can consult a personal trainer foran exercise regimen. A consulting relationshipwith a cardiologist for stress testing and othernoninvasive studies can complement the medicaland spa services.

INNOVATION AND CUTTING EDGE

The medical spa concept is new and exciting.Patients, clients, and physicians have recognizedthe desire for effective and convenient aesthetic-based services, and the emergence of themedical spa meets this desire. Providing theappropriate spa services and creating a pamper-ing care environment is adds value for a dermatol-ogy practice. When incorporating medical spaservices into the practice, the dermatologistshould remember that he or she is the leader,and the entire team must support the transition.One must demand consistency of services fromthe staff and promote continuing education andtraining. Assertive marketing, branding, and man-aging of the medical spa are crucial componentsof long-term success. Diligent management withrapid response to changes in the marketplaceand continued innovation will ensure the successof the medical spa.

REFERENCES

1. DeVierville JP. Spa industry, culture and evolution:

time, temperature, touch and truth. Massage &

Bodywork 2003;18(4):20–31.

2. Frost G. The spa as a model of an optimal healing

environment. J Altern Complement Med 2004;

10(Suppl 1):85–92.

3. Frosh WA. ‘‘Taking the waters’’—springs, wells, and

spas. FASEB J 2007;21:1948–50.

4. Routh HB, Bhowmik RK, Parish LC, et al. Balneology,

mineral water, and spas in historical perspective.

Clin Dermatol 1996;14:551–4.

5. International Spa Association web site. Available

at: http://www.experienceispa.com/ISPA/. Accessed

October 2007.

6. American Society for Aesthetic Plastic Surgery sur-

vey. Availabe at: http://www.surgery.org/download/

2005stats.pdf. Accessed October 2007.

7. Lauer C. Branding lesson. Mod Healthc 2006;

36(29):26.

8. Fairfield JC. Refined marketing. Advance for Healthy

Aging 2007;3(3):27–9.

9. Elsner P, Maibach H, editors. Cosmeceuticals and

active cosmetics. Boca Raton (FL): Taylor & Francis

Group; 2005.

10. Rokhsar KC, Lee S, Fitzpatrick R. Review of photore-

juvination: devices, cosemeceuticals or both?

Dermatol Surg 2005;31:1166–78.

11. Kockaert M, Neumann M. Systemic and topical drugs

for aging skin. J Drugs Dermatol 2003;2:435–41.

12. Kligman CH, Gans EH. Re-emergence of topical reti-

nol indermatology. J DermatologTreat 2000;11:47–52.

13. Miller R. Dermatologists should guard their patients’

purse, not pick their pockets! Arch Dermatol 1999;

135:255–6.

14. Gormley D. There is nothing wrong with dermatolo-

gists selling products to patients! Arch Dermatol

1999;135:765–6.

15. Goldbar J. Point: dermatologists should promote

treatment products. J Cutan Med Surg 1999;3(3):

145–6.

16. Gratton D. Counterpoint: the things you do for

money? J Cutan Med Surg 1999;3(3):146–7.

http://www.experienceispa.com/ISPA/

http://www.experienceispa.com/ISPA/

http://www.surgery.org/download/2005stats.pdf

http://www.surgery.org/download/2005stats.pdf

Personal Decisionsin a Dermatology Spa
Michael H. Gold, MDa,b,c,*
KEYWORDS� Dermatology spa � Medical spa � Aesthetician� Cosmetic dermatology � Cosmeceuticals� Skin care products � Ethical dispensing

A dermatology spa and a medical spa (medi-spa)are basically the same entity: a spa environmentlocated within a dermatology clinic. The spa maybe within the actual space of the dermatologymedical or cosmetic practice, or in a separatelocation somewhere near the medical practice.By its very nature, a dermatology spa is a spathat has an association with a dermatologist andtheir staff.

The spa business in the United States is boom-ing. More and more of these facilities are openingup, almost on a daily basis. Not only are theowners of these establishments dermatologists,but more and more spas are being run by otherphysicians or, more alarmingly, by people whoare unfamiliar with treating skin conditions of anykind and who appear only interested in cashingin on a fad.

With all of these spas opening up all over thecountry, it appears that there are just as many ofthem closing their doors or looking for associa-tions with clinicians who know something aboutthe skin and who have name recognition in theircommunity. I was recently approached by sucha business entrepreneur who had spent threeyears trying to make his strip-mall medi-spawork. He then realized, with all of the costs asso-ciated with running such a business and with allthe competition in the area, that his businesswould not be able to make it on its own. He waslooking for a ‘‘name’’ to add credibility to his

a Gold Skin Care Center, Tennessee Clinical Research CenTN 37215, USAb Division of Dermatology, Department of Medicine, VaUniversity Nursing School, Nashville, TN, USAc Huashan Hospital, Fudan University, Shanghai, China* Gold Skin Care Center, Tennessee Clinical Research CenTN 37215.E-mail address: [email protected]


business. I passed on the offer because I haveenough ‘‘on my plate’’ at this time and I foundthat the numbers just did not make sense.

Why would a dermatologist be interested instarting a dermatology spa in the first place?What possible benefits could be gained by a der-matology practice? And why would one want toinvest money into something which has very littleto do with what we physicians went to school allthose years for? These are the typical questionsthat I get asked when I lecture to young residentsand practitioners on the subject at medical meet-ings. There are no easy answers, just my opinionsafter almost 17 years of running a fairly successfuldermatology spa. In this article, I outline about howI ran my spa and the formulas we have used tomake our dermatology spa a success in ourcommunity.

When I first opened my dermatology practicemany years ago, I was a medical dermatologistwho had received wonderful resident training inthe cosmetic aspects of dermatology. It was notunusual in my residency program to be helpingperform hair transplants, scalp reductions, lipo-suction, chemical peels, sclerotherapy, collageninjections, and laser therapy (although it was inits infancy at that time). When I started my ownpractice, I began to incorporate these cosmeticprocedures into my practice. I enjoy the cosmeticpractice very much and I have continued to growits part in my dermatology practice over the years.

ter, 2000 Richard Jones Road, Suite 220, Nashville,

nderbilt University Medical School, Vanderbilt

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The cosmetic part of my practice led me to estab-lish a separate, but associated, entity near mymedical practice that provides strictly cosmeticprocedures, specifically laser therapies and injec-tions of fillers and toxins. The dermatology spaconcept developed earlier, just one year into mymedical practice of dermatology.

I saw an unmet need in our community when mypatients were asking me what kind of cleanser touse, what kind of creams and lotions should beapplied to the skin, and, more importantly, whatkind of products should be used when the patientshad a dermatologic condition. Expert recommen-dations were needed. Those needs were surelynot being met in my community; there was anopportunity to begin something new, somethingnot many had ventured into.

The concept began to take shape: developa place where all of a client’s skin care needs couldbe met in a one-stop shopping environment. Yes,a one-stop shopping environment was preferredbecause dermatologists know more about skincare and the needs of the skin than anyone else.Why shouldn’t dermatologists be the ones torecommend skin care products, perform servicesthat actually make sense, and work with medicalconditions normally seen on a daily basis? Ourdermatology spa concept began and it has beenused for 17 years (Fig. 1).

In the beginning, I had no idea how to do thisand no idea what products or services to provide.There were no ‘‘how to’’ books or consultantsavailable to get things started. I had to do this onmy own. I began to look around my communityto find the person I thought had the most knowl-edge in the aesthetics business and I hired her. Ipaid her more money than she had been makingin her cozy spa environment and I gave her theopportunity to help build a business from scratch.

She had a clientele, all of whom were willing tofollow her to her new home in my business. Thishad other benefits as well such as instant consultswith many wanting cosmetic procedures, and so itwas a perfect win-win situation for me.

I gave this aesthetician one of my examinationrooms that was made to look and feel a little lessmedical than the other rooms in my clinic. I taughther the basics of acne, eczema, what ingredientsin skin care products were good for the skin, andwhat ingredients might be irritants to the skinand should therefore be avoided. There was-another problem: we had no skin care productsto sell as there were no companies that actuallysold skin care products to physicians at the time(which is hard to believe now). Through someconnections I made while I had been a resident, Iwas able to arrange a deal with a major skin carecompany: we would have all of their products foruse for our services and we would recommendspecific products that our clients could purchasefor a discount at a nearby department store. Thiswas not the concept that I had when I started,but it was a good start.

The aesthetician began performing facials in herroom with her clients. In turn, her clients all eventu-ally found their way to purchasing the cosmeticprocedures I was performing, which helped mycosmetic practice blossom in those early years. Iwas sending her patients for facials and she wassending clients to me for collagen, chemical peels,sclerotherapy, and laser procedures (Fig. 2). Thisis where I found the first benefit of a dermatologyspa: cross-referrals through a built-in network ofpatients and clients whom we all shared, primarilymy dermatology patients and her aesthetic clients.Things were off to a great start: she was makingmore money than she had ever made before,had benefits which she never had before, and

Fig. 1. Advanced Aesthetics Medi-Spa ofGold Skin Care Center, Nashville,Tennessee.

Fig. 2. Spa room. Advanced Aesthetics Medi-Spa ofGold Skin Care Center, Nashville, Tennessee.

Personal Decisions in a Dermatology Spa 323

was providing a wonderful service to an entire newgroup of people not used to this one-stop shop-ping environment.

We realized, however, that for a one-stop shop-ping environment, sending clients to a departmentstore for products was not going to work, eventhough we were recommending the productsthat we wanted our clients to use. We began look-ing around the dermatology community and wesoon found that there were ‘‘cosmeceutical’’ skincare products popping up in dermatology. Webegan to purchase skin care products from someof these companies; we also recommended theproducts, when appropriate, to the clients receiv-ing services from our aesthetician. Finally, the con-cept of one-stop shopping had been realized.

The key to the medi-spa’s one-stop shoppingenvironment was keeping it ethical. We neverhave forced our patients to purchase our skincare products, but we do give them recommenda-tions, and often samples, of products that we wantthe clients to use. We have found over the yearsthat by keeping the product sales ethical, ourclients never feel pressured to purchase theseproducts and, most of the time, they will eventuallypurchase the products that we recommend.

After a few years in this environment, we hadoutgrown our medical space and we moved intoa new clinic, which we built with the spa in a com-pletely separate space. We hired a second

aesthetician and expanded our offerings to includemore and more spa services. Although the majorityof the services were medically related, some ser-vices were more cosmetic in nature. Because wefound that there were more skin care companiesselling products to dermatologists, we were ableto expand our product inventory as well. The der-matology spa part of my medical practice begangrowing nicely: the aestheticians were continuingto make more money than they had ever made,and more clients were receiving cosmetic proce-dures from me. We have never looked back.

Currently, we have a full service dermatologyspa with aestheticians and massage therapists.We sell over 500 skin care products to our clients.We rely heavily on the cross-referral system; wesee a lot of patients in our medical dermatologypractice and our laser and rejuvenation centertakes care of many patients in their dedicatedspace. Our dermatology spa serves many of thesepatients by recommending skin care products andperforming services, which include facials, micro-dermabrasions, and massage therapy. Theprogram has worked successfully for 17 years;we have used many aestheticians and massagetherapists who have been integral factors in ourcontinued growth.

There are no actual formulas that I used; per-haps ‘‘trial and error’’ would be the best way todescribe how we have grown over the years. Thereare many decisions that a clinician will have tomake in deciding how to run a dermatology spa.I will share some of the types of decisions. The firstdecision is to determine whom you will hire to per-form the spa services. As I stated, I found the bestaesthetician available in my area, who already hadestablished client base. This was a smart move forme. Since then, I have hired aestheticians whowere recent graduates from aesthetic schoolsand who were excited to learn and venture intothe dermatology spa business. The second deci-sion is about what services you are going to offerto your clients. This one isn’t as easy for mostdermatologists as many of us have no real conceptof the aesthetician’s language for facials and otherservices. You will need to learn the language andwork with your aestheticians to find the servicesthat go well with your dermatology practice.

Additionally, you need to decide if the offeredservices will be strictly medical in nature, cosmetic,or a blend of both. We have always found thata blend of both works best for our clientele.Some patients/clients need the more medicalacne/eczema-related services and some needmore pampering; both types of services can workin the dermatology spa environment. You willneed to decide which choices work best for you.

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Also, you need to decide how you are going topay the staff. This group of individuals works fordifferent pay rates and scales than your typicalmedical employees. Most of the aestheticiansin the general community work either for a percent-age of what they make or on a strict split of theircharges. Either method is okay, but I have alwaysfound that it is best to have these employees ona salary, usually paying them by a set hourlywage. We always pay more than the normal ‘‘go-ing’’ rate to ensure that our aestheticians are wellcompensated and feel part of the team. Oncethey work more than thirty hours per week, we al-low them to enjoy the other benefits we give to ourother employees, which include health insurancebenefits, disability benefits, and enrollment intoour retirement program. I promise that for the ma-jority of aestheticians and massage therapists thisis a new concept for them and you can help youdifferentiate your business from others in the com-munity. We then add a bonus plan that in our caseis a commission on products sold, which usuallyruns around 5% for our aestheticians and mas-sage therapists.

With the skin care products themselves, there isno set formula that I am aware of which works forall dermatology spa settings. I have always chosento work with skin care companies that supportdermatology and then we have the assistance ofthe local support available to us to help move theirproducts. These companies need to earn theirplace in our office; it is not a given that a skincare company will remain with us unless there ismutual help between the company and our derma-tology spa.

What do I mean by this? There are several wayscompanies can help you grow your business. Theycan support your advertising initiatives by payingfor some of your advertising or by coming upwith individualized advertising for your spa. Bybuying skin care products, you should earn co-operative (co-op) dollars, which then can beused for your own internal promotions. We insiston this with all of the companies that we purchaseskin care products from. We also insist that thesales representatives from these companies helpus with local, in-house promotional activities,which we have from time to time to promotecertain products and services.

I only use skin care products from well-respected dermatology companies; however,there is another form of products, known as pri-vate-label products that also serve many in ourgroup well. There are now several well-establishedprivate labeling companies out there, and thelabeling can brand the product yours. Those usingprivate labeling should be ethical in letting their

patients know that these products were notmade by them, but have their name on them.Also, let patients know that these labeled productsare not the only skin care products that will takecare of a particular problem or concern. Again,keeping the selling ethical is very important. Wealso expect that all of the companies that we pur-chase products from will have products availablefor use as back-bar stock; these are productsthat the aestheticians actually use on a daily basiswith their clients.

After you have your staff hired and have decidedwhich skin care products you are going to sell, youneed to have several items in place to assure thesmooth running of your dermatology spa. Youneed to have an inventory control system; some-one knowledgeable about inventory managementwill need to control the products you have onhand. We use our in-house accountant, in concertwith our spa staff, to handle our inventory needs.Products are ordered by the spa’s staff withpurchase orders; the purchase orders go to ouraccountant for approval. Once the products havearrived, they are inventoried in our computer sys-tem before they make their way onto our shelves.

Spa practice-related software also exists whichcan help you track your clients and help withscheduling, confirmations, and follow-up. Thesesoftware programs are usually not part of yourtypical electronic medical record software pack-ages, although that would surely reduce the effortsof our information technology team, which mustkeep up with all of this software. Tracking your cli-ents is extremely important: where do they comefrom and who sent them to you? Are your clinic’spatients making their way to your dermatologyspa? Are your cosmetic patients buying skin careproducts post-procedure to help maintain theirskin? Are you receiving new clients from regularclients? And from where else are you getting cli-ents? Tracking these clients is crucial to the suc-cess of a dermatology spa.

You will also need to determine if you are goingto advertise your dermatology spa. The forms ofadvertising you choose will help you make a decentreturn on your investment. I chose to advertise mydermatology spa, initially, in print advertising,especially when I could use co-op dollars to helpoffset the expenses. I found these ads workedonly fairly well. By far, our best means of marketingis our internal marketing, using the nearly 95,000patients who already exist in our database. Weroutinely send out e-mail blasts to this groupletting clients know weekly specials on productsand services.

We create a newsletter at least two times peryear that is of magazine quality and describes

Personal Decisions in a Dermatology Spa 325

the many facets of our center, also focusing on ourdermatology spa and its employees. The newslet-ter concept has been, by far, our most successfuladvertising tool; I encourage all dermatologists todevelop a newsletter that can educate your pa-tients and separate you from your competition.

I have truly enjoyed running a dermatology spathese past 17 years. I have seen the environmentchange dramatically over time, with many spasopening and many closing. I believe that the spabusiness is not going to lead one to retire from the

income it can potentially make. At times, with all ofthe expenses you might allocate to your spa, youcan actually lose money in the spa. If there arecross-selling efforts and referrals being made, andif ourspaclientsare receiving othercosmetic proce-dures that are more expensive, then the spa servesa great purpose for my clients and for me. I encour-age everyone in dermatology to embrace the spaconcept and to allow those who know how to runone efficiently, professionally, and ethically to havea place in our wonderful dermatology family.

Technology Approachesto the Medical Spa: ArtPlus Science EqualRejuvenation
Mitchel P. Goldman, MD
KEYWORDS� Medical spa � Cellulite � Rejuvenation � Hair

Medical spas are the fasting growing segment ofthe 15-billion dollar spa industry. Although medicalspas have been in existence since ancient times totreat a wide variety of ailments such as gout, arthri-tis, and diabetes, our modern concept of themedical spa combines relaxation with medicalrejuvenative procedures. In Europe, the firstattempts at medical rejuvenation occurred withnutritional supplements, colonic cleansing, and in-travenous therapy with a variety of hormones andanimal-based extracts. The location of medicalspas near thermal springs has been important,and even Napoleon had a spa build at La RochePosey to treat the topical wounds of his warveterans.

The use of oral and topical waters and supple-ments also occurred in the ‘‘New World.’’ Thisarticle focuses on the more recent technologicadvancements in rejuvenation.

com

MODERN HISTORYOFMEDICAL SPATECHNOLOGY

This author believes that the modern explosiveevolution in medical spas coincided with thedevelopment of intense pulse light (IPL) and lasertreatments for hair removal. This coincided withthe recognition that epilation of hair from areastreated with the IPL was not a side effect of theIPL (as reported to the FDA in our initial studieson the treatment of vascular lesions with the IPL)but was a new treatment for excessive orunwanted body and facial hair. The companythat first developed the IPL under the name Photo-derm VL (Energy Systems Corporation, Ltd., now

La Jolla Spa MD, 7630 Fay Avenue, La Jolla, CA 92037, UE-mail address: [email protected]


Lumenis, Inc., Santa Clara, CA) recognized thathair loss after IPL treatment was a new business.They modified the Photoderm to have a largespot size and more powerful fluence and calledthe new machine the ‘‘Epilyte.’’1 Clinics devotedto hair removal, such as Vanishing Point, werestarted, and physicians added the Epilyte to theirpractices. The Epilyte became so successful thatin 1998 our practice dedicated an adjoining officespace to the medical suites to house the Epilyteand added facials, massage, and hydrating treat-ments and called the new business The Spa atDermatology Associates. Within a few months,the ‘‘Spa’’ became profitable, primarily due to thesuccess of IPL hair removal. Laser companiestook note, and the 810-nm diode Lightshear(Palomar/Coherent/Lumenis) and the long-pulsed755-nm Alexandrite lasers (Candela and Cyno-sure) were developed.

In the late 1990s, physicians who had been usingthe IPL for hair removal and to treat leg veins andother vascular lesions noticed that solar lentigoslightened or resolved when coexisting vascularlesions were treated, and the skin took ona smoother appearance and feel.2 Dr. Patrick BitterSr. and Dr. Patrick Bitter Jr. termed this effect‘‘photofacial,’’ (now known as ‘‘photorejuvena-tion’’), and the medical spa had a second largeclientele. The development of minimally or nonin-vasive lasers that could also produce rejuvenationof photodamaged skin were developed andcontinue to be improved upon. More recent skin-tightening radiofrequency (RF) or infrared deviseswere developed to treat fine lines, wrinkles, andskin elasticity. Most recently, women have been

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Box 2Commonly reported problems from nonphysicianpractice of medicine

Cutaneous burns

Post-treatment hyperpigmentation

Scarring

Post-treatment hypopigmentation

Delayed healing from infections

Corneal and retinal injury due to inadequateeye protection

Goldman328

educated as to the undesirable appearance of thenatural female characteristic of cellulite, promptingthe development of yet another treatmentmodality.

In summary, the technological advances were inthe treatment of unwanted hair, photodamagedskin, and cellulite. One could also make a casefor the treatment of tattoos and fatty deposits,but a discussion of every possible treatment isbeyond the scope of this article. This articlefocuses on the three most important and commonmedical spa treatments.

Spa Nursing Personnel: Who Should DeliverMedical/Technologic Care?

Equipment available to vaporize hair, reduce signsof photodamage, improve the appearance ofcellulite, and tighten skin has become easier touse over the last few years. This ease of use hasresulted in the ability of nonphysicians to serveas technicians, which permits widespread use.Because nonphysicians receive less training thanphysicians, they charge less for their services onan hourly basis. The use of nonphysicians to oper-ate rejuvenating equipment translates to a lowercharge per procedure or a higher profit marginfor the owner of the equipment. Many rejuvenatingprocedures use laser, IPL, and (RF) technology,and these procedures are not fool-proof and cancause adverse effects. Because United Stateslaw delegates the responsibility of public safetyto State governments, rules and regulationsgoverning the use of these machines are not uni-form or are non-existent. Despite this variabilityof State regulation, common ethics dictates thatone should strive to provide safe and effective pro-cedures. The dangers of inappropriate delegationof medical procedures are listed in Box 1. Com-mon problems seen from nonsupervised medicalprocedures are listed in Box 2.

Some states, such as Georgia, do not requiretraining or testing of competency of physiciansupervision in using lasers, RF, or IPL devices.

Box1Dangers of nonphysician practice ofmedicine

Impaired patient safety

Adverse events from treatment

Failure to treat adverse events from treatment

Unnecessary or inappropriate treatment

Excessive treatment

Subordination of patient well-being to fin-ancial productivity secondary to financialincentive

Other states, such as Florida, require that the phy-sician who supervises a nurse on sight be a derma-tologist or plastic surgeon. The problem is that theAmerican Society for Dermatologic Surgeryestimates a 25% increase in complications fromusing these procedures by nonphysicians overthe last 5 years. Therefore, the American Academyof Dermatology and the American Society forDermatologic Surgery in 2004 approved a positionstatement that required a supervising physician tobe present and immediately available to respondto problems associated with nonmedical adminis-tration of IPL, RF, or laser treatments. The Ameri-can Society of Laser Medicine and Surgery in1999 took a similar stance and added that thesupervising physician must be trained and certi-fied to administer the treatments s/he is supervis-ing and be within 5 minutes of the nonphysician.The American College of Surgeons takes a morerestricted position in their 2007 regulations, statingthat individuals who perform these procedures belicensed physicians with the same certificationthat governs all surgical procedures. Ultimately,the delegation of patient care depends on theethical standards of the medical director. Asphysicians, we took an oath not to make themost money possible but to deliver the best carewe can and do no harm.

Hair Removal Lasers

The first laser assisted hair removal device wasmarketed in 1996. Such hair removal devices in-clude ruby, alexandrite, diode, and neodymium:yttrium aluminum garnet (Nd:YAG) lasers and IPLsources.

MECHANISMS OF HAIR FOLLICLE DESTRUCTION

There are three means by which light can destroyhair follicles: thermal (due to local heating), me-chanical (due to shockwaves or violent cavitation),and photochemical (due to the generation of toxicmediators like singlet oxygen or free radicals). For

Art Plus Science Equal Rejuvenation 329

our purposes, photothermal destruction is themost important factor.3

Photothermal Destruction

Photothermal destruction is based on the principleof selective photothermolysis. The principle statesthat by choosing an appropriate wavelength, pulseduration, and fluence, thermal injury can be confinedto a target chromophore.4 In the visible to near-infra-red region, melanin is the natural chromophore fortargeting hair follicles. It is found in the hair shaft,the outer root sheath of the infundibulum, and thematrix area. Lasers or light sources that operate inthe red or near-infrared wavelength region (694-nmruby laser, 755-nm alexandrite laser, 800-nm diodelaser, 1064-nm Nd:YAG laser, and noncoherent lightsources with cut-off filters) lie in an optical window ofthe electromagnetic spectrum where selectiveabsorption by melanin is combined with deep pene-tration into the dermis. Because melanin in the epi-dermis presents a competing site for absorption,cooling of the epidermis with cold air, a cryogenspray, or a cold sapphire window minimizes epider-mal injury.5 The pulse duration of the laser should bematched to the thermal relaxation time of human ter-minal hair follicles, which is estimated to be about 10to 100 milliseconds.

Hair removal is also dependent upon fluence.Careful studies with computerized hair countshave demonstrated that greater hair loss wasachieved at the higher fluences tested. The limitingfactor is damage to the skin, which determines thehighest tolerated fluence.

CLINICALTECHNIQUEPatient Selection

The individual’s skin type and hair color andcoarseness determine which device is the mostappropriate and help to predict response to treat-ment. The ideal patient has realistic expectations,normal endocrine status, thick dark hair, and lightskin tones. Current techniques are not generallysuccessful in permanently removing white hairsor fine vellus hairs. Laser treatment is much moreeffective when the pigmented hair shaft is presentwithin the follicle. Patients should therefore notpluck or wax for at least 6 weeks before treatment.Shaving, bleaching, or using chemical depilatoriesis an acceptable alternative for patients awaitinglaser treatment. Due to the increased risk for eyeinjury, patients should not be treated within theorbital rim. Certain medications and hormonalimbalances may inhibit permanent hair removaldue to hair stimulation. Although treatment canbe safely performed with a shorter wavelength de-vice (eg, ruby laser) in fair-complected patients, it

is preferable to use a longer wavelength devicein darker-complected patients. Further epidermalprotection is afforded by using longer pulse dura-tions and active cooling. When assessing individ-uals who have a suntan, it is usually prudent todelay treatment until fading of the tan occurs.

Laser Selection

755-nm alexandrite lasersSeveral long-pulsed alexandrite lasers (755 nm)are available for hair removal. These lasers providepulse durations between 5 and 40 millisecondsand fluences up to 50 J/cm2. A cooling handpieceallows a continuous flow of chilled air to the treat-ment area, or dynamic cryogen spray coolinggives short (5–100 milliseconds) cryogen spurts,delivered on the skin surface through an electron-ically controlled solenoid valve; the quantity ofcryogen delivered is proportional to the spurtduration. The liquid cryogen droplets strike thehot skin surface and evaporate. Skin temperatureis reduced as a result of supplying heat forvaporization.6

Most studies demonstrate 70% clearing of hairfor at least 6 months after five treatments.6,7 Sideeffects are rare, with postinflammatory hyperpig-mentation at high fluencies. The longer pulsedurations provided better protection to the epider-mis. Cryogen spray cooling has been associatedwith rings of hypopigmentation.8 Pigmentary prob-lems usually resolve within 1 year.

800-nm diode lasersAn extremely high-powered (2900W) diode laser(LightSheer; Lumenis) is a popular laser hair re-moval device. Long-term results suggest that thepulsed, 800-nm diode laser is effective for theremoval of dark, terminal hair: Permanent hairreduction of 70% or more can be obtained.9,10

This laser operates at 800 nm and has pulse widthsbetween 5 and 400 milliseconds, a 12�12 mmspot, a 2 Hz repetition rate, fluences rangingfrom 10 to 60 J/cm2, and a patented contact cool-ing device (ChillTip). Because of the longer wave-length, the active cooling, and the longer pulsewidths, darker skin types can be treated moresafely than with the Alexandrite lasers. The majordrawback is that the use of this laser requirescontact with the skin surface, making it difficultto use in the pelvic region.

Long-pulsed 1064-nm Nd:YAG lasersSeveral long-pulsed Nd:YAG lasers (1064 nmwavelength) that deliver pulses in the milliseconddomain are available for hair removal laser treat-ment on all skin types. The long-pulsed 1064 nmNd:YAG laser is deeply penetrating.11 The

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reduced melanin absorption at this wavelengthnecessitates the need for high fluences to ade-quately damage hair. The poor melanin absorptionat this wavelength coupled with epidermal coolingmakes the long-pulsed Nd:YAG a potential safelaser treatment for darker skin types up to VI.12,13

The Nd:YAG laser is also often used for treatmentof pseudofollicultis barbae, a skin condition com-monly seen in darker skin types.14

Pulsed, Noncoherent Broadband Light Sources

Intense pulsed, nonlaser light sources emittingnoncoherent, multiwavelength light have beenused for hair removal (EpiLight; Lumenis; Ellipse,Danish Dermatologic Development, Hørsholm,Denmark). By placing appropriate filters on thelight source, wavelengths ranging from 590 to1200 nm can be generated. Cut-off filters areused to eliminate short wavelengths so that onlythe longer, more deeply penetrating wavelengthsare emitted. Pulse durations vary in the milliseconddomain. A single-or multiple-pulse mode (2–5pulses) with various pulse delay intervals can bechosen. The wide choice of wavelengths, pulsedurations, and delay intervals makes this devicepotentially effective for a wide range of skin types.The devices come with software that guides theoperator in determining treatment parametersdepending on the patient’s skin type, hair color,and coarseness.15,16

Electro-Optical Synergy Technology

Electro-optical synergy technology uses a synergybetween electrical (conducted RF) and optical(laser or light) energies. The electrical energycauses heat, which is focused on the hair follicleand the bulge area, whereas the optical energyheats mainly the hairshaft. When combined, a uni-form temperature distribution across the hairshaftand the follicle should be obtained to achieveeffective hair removal. Based on this electro-optical synergy technology, Syneron (YokneamIllit, Israel) has developed a system (Aurora) thatcombines RF energy with intense pulsed lightand is equipped with cooling. The use of the RFenergy should also allow for treatment of all skintypes because this form of energy is not absorbedby epidermal melanin.17

Aminolevulinic Acid

Photodynamic therapy (PDT) involves the use ofa photosensitizer and light to produce therapeuticeffects. The mechanism of action is presumed toinvolve the generation of toxic reactive oxygenspecies, subsequent to the photochemical activa-tion of the photosensitizer by light. The recent

introduction of 5-aminolevulinic acid as a topicalphotosensitizer has opened up a variety of poten-tial therapeutic options. Selective protoporphyrinIX synthesis in pilosebaceous units is a uniquefeature of ALA over other photosensitizers, andtopical application circumvents the photosensitiv-ity that is induced by systemic agents.

Preliminary reports from a recent study includ-ing, examined the ability of Levulan stick witha proprietary nonlaser light source comparedwith a laser to remove human hair. The nonlaserlight plus Levulan did not result in more significanthair loss than placebo plus light. Levulan plus laserlight seems to prevent approximately 30% of thehair from regrowing with one treatment (unpub-lished results from DUSA pharmaceuticals).

Photodynamic therapy may be a useful ap-proach for hair removal. Because photosensitizerstend to localize in the follicular epithelium, photo-chemical destruction of all hair follicles, regardlessof hair color or growth cycle, could be obtained.Long-term data and large-scale studies areneeded to determine the safety and long-termefficacy of this modality.18

Treatment Guidelines

The procedure for hair removal is similar using anyof the devices previously described. The idealtreatment parameters must be individualized foreach patient. Test sites can be placed at incon-spicuous sites in the area to be treated. The treat-ment fluence is carefully increased while the skin isobserved for signs of acute epidermal injury, suchas whitening, blistering, ablation, or Nikolsky’ssign. Slightly overlapping laser pulses should bedelivered with a predetermined spot size. It isrecommended that the largest spot size and thehighest tolerable fluence be used to obtain thebest results.

The ideal immediate response is vaporization of thehair shaft with no other apparent effect. After a fewminutes, perifollicular edema and erythema may ap-pear. The intensity and duration depends on the haircolor and hair density. If there is a sign of epidermaldamage, the fluence should be reduced.

Ice packs reduce postoperative pain and mini-mize edema. Analgesics are not usually requiredunless extensive areas have been treated. Mildtopical steroid creams may be prescribed toreduce post-treatment edema and erythema.Trauma (eg, picking or scratching) to the treatedarea should be avoided. During the first week ofhealing, direct sun exposure should be avoided,or sunblocks should be used. Make-up may beapplied on the day after treatment unless blisteringor crusts develop. The damaged hair is often shed


during the first few weeks after treatment. Patientsshould be reassured that this is not a sign of hairregrowth.

Laser hair removal requires the presence ofa pigmented hair shaft. Retreatment can be per-formed as soon as regrowth appears. Regrowthis based on the natural cycle, which varies byanatomic location, but on average, the timing is 6to 8 weeks.

Expected Benefits

Patients have different expectations of treatment(eg, temporary versus permanent, partial versuscomplete hair removal). All responses are clinicallysignificant and may be separately desirable for dif-ferent patients. Growth delay that provides a fewmonths of hairless skin is far more reliably achievedthan permanent hair loss. All laser systems havebeen shown to temporarily reduce hair growth forall hair colors (except white) and at all fluences.

Effectiveness for permanent hair reduction isstrongly correlated with hair color and fluence.Long-term, controlled hair counts indicate an aver-age of 20 to 30% hair loss with each treatment,indicating the need for multiple treatments to ob-tain near complete hair removal. Research alsoshows that in the ideal patient with fair skin anddark hair, the probability for long-term hair removalis about 80 to 89%, depending on the device used.Long-term comparison of different lasers (alexan-drite, diode, Nd:YAG) and light sources (intensepulsed light) indicates that effective long-termhair removal can be achieved with all systems.The alexandrite and diode lasers and IPL achieveabout the same results, with the 1064 nm Nd:YAGbeing much less efficacious and reserved for darkskin types.19–23

The maximum fluence tolerated is determined bythe epidermal pigmentation. Fair-skinned, dark-haired patients are most easily treated. Dark-skinned patients pose a greater challenge. Any ofthe hair removal devices are safe and effectivein light-skinned patients, whereas longer wave-lengths (near-infrared) and longer pulse durationshave been shown to treat darker skin types moresafely when combined with cooling devices. Forpatients presenting with recent sun exposure, pre-treatmentwith a bleaching agent, sunscreen, or sunavoidance is recommended before laser treatment.

The number of treatments needed to obtain thebest results for different anatomic sites is unknown.On average, five to seven hair-removal treatments,performed at 1- to 3-month intervals, are requiredto achieve a significant reduction of excess hair.A rare patient can obtain long–term, completehair removal after a single treatment, whereas

others may respond poorly for unknown reasons.Most patients (80–89%) respond favorably.

Often, regrowing hairs are thinner and lighter incolor, as indicated by measurements of diameterand color of regrowing hairs. This contributes tothe overall cosmetic outcome because the clinicalimpression of hairiness is not only defined by theabsolute number of hairs, but also by the colorand by the length and the diameter of the hairs.The range of outcomes can be summarized asabsolute hair number reduction; finer, lighterregrowing hair; and slower regrowth.

Intense Pulsed Light Photorejuvenation

One of the most controversial light based technol-ogies, which had its birthplace in San Diego in1992 and was cleared by the US FDA in late1995 as the Photoderm (ESC/Sharplan, Norwood,MA, now Lumenis), is the noncoherent polychro-matic filtered flashlamp IPL source. It was initiallylaunched and promoted as a radical improvementover existing methods for the elimination of legtelangiectasia due to pressure from venture capitalgroups that funded its development.1,24 Althoughthe treatment of leg telangiectasia was possible,additional advantages are the IPL’s ability asa specific modality to minimize the possibility ofpurpura common to pulsed dye lasers (PDL) andthe the elimination of hair and lentigines. Contin-ued use proved that the device was of far greaterutility for other indications than leg telangiecta-sias.2 The road to usability, reproducibility, andefficacy was a long one, with some clinical usersand many ‘‘laser experts’’ dismissing the IPL asharmful and useless. The term ‘‘photoburn’’ wascommonly used.25 It is ironic that the IPL is nowconsidered the gold standard for the treatment ofvascular lesions in addition to the many of thesigns of photoaging. Testimony to the acceptanceof the IPL as a valid efficacious technologic break-through is evidenced by over 20 different manu-facturers producing various forms of IPL with theestimated sale of 25,000 IPL devises worldwidein the last 15 years.

Although some IPL devices have one or two cut-off filters, available cut-off filters are 515, 550, 560,570, 590, 615, 645, 690, and 755 nm. To allowoptimal transmission of light by decreasing theindex refraction of light to the skin and promotinga ‘‘heat-sink’’ effect, filter crystals are often opti-cally coupled to the skin with various thicknessesof a transparent water-based gel.

The working premise for IPL is that noncoherent,polychromatic light can be manipulated with filtersto meet the requirements for selective photother-molysis (ie, for a broad range of wavelengths, the

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absorption coefficient of blood in the vessel ishigher than that of the surrounding bloodlessdermis). When filtered, the Lumenis IPL device iscapable of emitting a broad bandwidth of lightfrom 515 nm to approximately 1200 nm. (OtherIPLs have different wavelength outputs.) Thisbandwidth is modified by filters that exclude thelower wavelengths. Although the output is not uni-form across this spectrum, with the Lumenis IPL,during a 10-millisecond pulse, relatively highdoses of yellow light at 600 nm are emitted, withfar less red and infrared, although output hasbeen demonstrated beyond 1000 nm (Fig. 1).24

Allowing proper thermal relaxation time betweenpulses theoretically prevents the elevation of epi-dermal temperatures above 70�C and is an inher-ent advantage of ‘‘multiple sequential pulsing’’ ofthe IPL device. Thermal relaxation time is theamount of time it takes for the temperature of a tis-sue to decrease by a factor of e 5 2.72 as a resultof heat conductivity. For a typical epidermal thick-ness of 100 mm, the thermal relaxation time isabout 1 millisecond. For a typical vessel that is100 mm (0.1 mm), the thermal relaxation time is ap-proximately 4 milliseconds; for a vessel of 300 mm(0.3 mm), the thermal relaxation time is approxi-mately 10 milliseconds. Therefore, vessels greaterthan 0.3 mm cool more slowly than the epidermiswith a single pulse. For larger vessels, multiplepulses may be advantageous, with delay times of10 milliseconds or more between pulses for epi-dermal cooling. This delay time must be increasedwith larger vessels because thermal diffusionacross a larger vessel elongates the thermal relax-ation time. Multiple sequential pulsing with delaytimes permits successive heating of targeted ves-sel(s) with adequate cooling time for the epidermisand surrounding structures (Fig. 2).

The treatment of individuals who have darkerskin (types IV–VI) or patients with hyper-reactive

melanocytes becomes of increasing concernwhen performing photo-epilation. In these cases,the 755-nm filter is used primarily with delay timesbetween pulses from 50 to 100 milliseconds to al-low plenty of time for the skin to cool, therebyavoiding thermal damage.

The newest concepts for IPL and what has mostcontributed to the success of the technique is theability to elongate pulse durations for largervessels, to shorten pulse durations for smaller ves-sels, and to use these in a variety of combinationsof synchronized short and long pulse widths. Fora small vessel (0.3 mm), heat distribution isassumed to occur instantaneously. For a largervessel, this cannot be assumed because moretime is required for heat to pass from just insidethe superficial vessel wall through the vessel tothe deeper wall. Additional cooling time is requiredto release the accumulated heat from the core tothe vessel surface.

Treatment of Photoaging with IntensePulsed Light

Facial telangiectasiaThe treatment of facial telangiectasia is the foun-dation of treatment of photoaging by IPL. Clinicalobservations of smoother skin texture weremade after treatment of facial telangiectasia. Thisobservation was made by the author and otherstreating patients during 1995 through 1997.26,27

The advantage of the IPL over the PDL is thatwith the large spot size an entire cheek of telangi-ectatic matting can be treated with less thana dozen pulses in less than 5 minutes. In addition,there is little if any purpura. For larger, more purpletelangiectasias typically seen on the nasal alae orfor venous lakes or adult port-wine stains, thesame settings may be used as for small vesselsof leg (ie, a short pulse followed by a long pulse).

Fig. 1. Emission spectrum of an intensepulsed light head with the 515-nm filter at10-millisecond pulse duration. Peak outputshown by line is at 600 nm. (Courtesy ofHolger Lubatschowski, PhD, Hannover,Germany.)

0.1

1

10

100

1000

10000

400 500 600 700 800 900 1000

Wavelength [nm]

Ab

so

rp

tio

n/S

catterin

g co

efficien

t

[1/cm

]

dermis absorption

dermis scattering

oxyhemoglobin

deoxyhemoglobin

Fig. 2. Absorption curve of hemoglobin in different states of oxygenation. Because collagen absorbs little on itsown, the primary components absorbing light are hemoglobin and melanin (melanin not shown). There is a zonefrom 600 nm to 750 nm in which deoxyhemoglobin has preferential absorption. (From Goldman MP, FitzpatrickRE. Cutaneous laser surgery: the art and science of selective photothermolysis. 2nd edition. St. Louis (MO): Mosby;1999; with permission.)


Poikiloderma of civatteThis photoaging process consists of an erythema-tous, pigmented, and finely wrinkled appearancethat occurs in sun-exposed areas, mostly on theneck, forehead, and the upper chest. For areasof poikiloderma on the neck and lower cheeksconsisting of pigmentation and capillary matting,the IPL device is ideal with the use of a 515-nmfilter, which allows absorption by melanin and he-moglobin simultaneously. For patients who havemore dyspigmentation, treatment begins withhigher filters, such as the 550-nm or 560-nm filter,to prevent too much epidermal absorption, whichcauses crusting and swelling that lasts for severaldays. Additional treatments with the IPL may beperformed with a 550-, 560-, or 570-nm filter totreat the vascular component of poikiloderma.28

Photorejuvenation

The overall appearance of aging skin is primarilyrelated to the quantitative effects of sun exposurewith resultant UV damage of structural compo-nents, such as collagen and elastic fibers. Appear-ance is also affected by genetic factors, intrinsicfactors, disease processes such as rosacea, andthe overall loss of cutaneous elasticity associatedwith age. With excessive sun exposure, visiblesigns of aging have become more evident in youn-ger individuals. Photorejuvenation has beendescribed as a dynamic, nonablative processinvolving the use of the IPL to reduce mottled pig-mentation and telangiectasias and to smooth the

textural surface of the skin. The treatment is gener-ally administered in a series of two to five proce-dures in 3- to 4-week intervals. The entire face istreated, rather than a limited affected area, andthe patient may return to all activities immediately.Marketing has made the public and medical com-munity aware of these changes through variousunsuccessfully applied for service trademarks,such as Photofacial, Fotofacial, and Facialite.

Zelickson29,30 demonstrated that IPL treatmentresults in an 18% increase in collagen Type-1 tran-scripts, whereas PDL treatment results in a 23%increase in collagen Type-1 transcripts. This mayexplain the improvement in fine wrinkling with pho-torejuvenation.A further investigation demonstratedthat collagen I and III, elastin, and collagenaseincreased in 85 to 100% of patients and that procol-lagen increased in 50 to 70% of patients.

Hernandez-Perez and colleagues31 evaluatedthe histologic effects of five IPL treatments with570 to 645 nm, 2.4 to 6.0 milliseconds, delay20 milliseconds, 25 to 42 J/cm2. They showedepidermal thickening of 100 to 300 mm, bettercellular polarity, a decrease in horny plugs, newrete ridge formation, decreased elastosis, and der-mal neocollagen formation.

Weiss and colleagues27 evaluated 80 of their initialpatients treated for vascular lesions to determine ifphotorejuvenationoccurred. Images fromthreesub-sequent visits, including one follow-up at 4 years,were graded. There was an 80% improvement inpigmentation, telangiectasia, and skin texture.Hypopigmentation lasting for 1 year occurred in

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2.5%, temporary mild crusting occurred in 19%, er-ythema for more than 4 hours occurred in 15%,hypo- or hyperpigmentation occurred in 5%, andrectangular foot-printing occurred in 5%.

In a recent study, 49 subjects who had varyingdegrees of photodamage were treated witha series of four or more full-face treatments at3-week intervals using IPL (Vasculight IPL; Lume-nis). Fluences varied from 30 to 50 J/cm2 with typ-ical settings of double- or triple-pulse trains of2.4 to 4.7 milliseconds and pulse delays of 10 to60 milliseconds. Cut-off filters of 550 or 570 nmwere used for all treatments.32 Photodamage,including wrinkling, skin coarseness, irregular pig-mentation, pore size, and telangiectasias, wasimproved in more than 90% of the patients. Treat-ments involved IPL of the entire facial skin exceptin male patients who elected to avoid treatment ofthe beard area because of potential hair loss. Inthis study, 72% of subjects reported a 50% orgreater improvement in skin smoothness, and44% reported a 75% or greater improvement.Minimal side effects were reported, with tempo-rary discoloration consisting of a darkening oflentigines, which resolved within 7 days. Two sub-jects reported a ‘‘downtime’’ of 1 and 3 days dueto moderate to severe swelling.

The dual-mode filtering IPL system, Elipse FlexDDD (Danish Dermatologic Development, Copen-hagen, Dennmark), was evaluated in 20 women forfacial photorejuvenation.33 First, areas of telangi-ectasia were treated with a pulse duration of 14to 30 milliseconds. A second pass was thenmade with a double pulse of 2.5 millisecondswith a 10-millisecond delay. Two types of filterswere used: 530 to 750 nm at an energy level of11 to 17 J/cm2 and 555 to 950 nm at a fluence of13 to 19 J/cm2. Both groups reported significantimprovement in telangiectasia and pigmentationwithout adverse sequelae.

Newer IPL systems have increased the efficacyof treatment by providing a more uniform distribu-tion of energy over the pulse duration. Twentypatients of Fitzpatrick skin types I through III, eachwith components of photodamaged skin includingtelangiectasias, dyschromia, skin roughness, en-larged pore size, or rhytides, received with a singletreatment of the Lumenis One IPL. The resultsshowed an average of 40% improvement in resolu-tion of telangiectasias, dyspigmentation, and finewrinkling. Previous studies with IPL using otherIPL systems found that three to five treatmentswere needed to obtain a similar improvement.These IPL systemshave a smaller spot size,a differ-ent energy output profile, and a cutaneous coolingmechanism, which may explain their decreasedefficacy compared with the Lumenis One.34

Photodynamic Skin Rejuvenation

The combination of IPL and photodynamic therapysensitizers, such as 5-amino levulinic acid (ALA)(Levulan; DUSA Pharmaceuticals, Wilmington,MA), allow for new options in the treatment ofseverely photodamaged skin and may offera significant cosmetically beneficial alternative tophotodynamic treatments with blue light for suchconditions as actinic keratoses, early skin cancers,and cystic acne.

We have termed this advanced technique ‘‘pho-todynamic skin rejuvenation’’. The photodynamicskin rejuvenation application of PDT involves acti-vation of a specific photosensitizing agent, 5-ALA,activated by the conventional IPL. This processproduces activated oxygen species within cells,resulting in their elimination or destruction. Thetopically active agent, ALA, is the precursor inthe heme biosynthesis pathway of protoporphy-rin-9, which facilitates cellular destruction. Exoge-nous administration of ALA, along with 410-nmcontinuous blue light, has been FDA cleared forthe treatment of actinic keratosis and seems tohave significant long-term efficiency. In clinicalpractice, a variety of light sources has been usedin photodynamic therapy to reduce time and dis-comfort for patients and to enhance the clinicaland cosmetic outcome of the procedure.35

IPL treatments have shown enhanced benefitsof photodynamic therapy. Short-duration PDT,using Levulan for 60 minutes coupled with a treat-ment of IPL, has shown significant benefit in thetreatment of precancerous conditions such asactinic keratoses and in the treatment of actinicallydamaged skin with a significant degree of cos-metic enhancement.36

Great benefit is seen with topical ALA and IPLskin treatments using photorejuvenation in condi-tions such as moderate to severe acne and rosa-cea. The mechanism for improvement in acneand rosacea is due to the enhanced absorptionof ALA by sebaceous glands. This enhancedabsorption followed by photoactivation with IPLdamages the sebaceous gland, causing its involu-tion. A decease in the size or activity of the seba-ceous gland leads to an improvement in acne.37,38

Adverse Reactions

In our experience with thousands of treatment ses-sions, there has been about a 2% incidence ofscattered areas of crusting in areas of increasedpigmentation. This typically heals within 7 daysby peeling off. We accelerate this process byhaving the patients apply a moisturizer twicea day or undergo a treatment with microdermabra-sion 1 to 2 days after IPL treatment. When there is


no underlying pigmentation, crusting occurs pri-marily on curved body areas, such as the neckover the sternocleidomastoid muscle curvature.Purpura occurs in scattered, isolated pulses inabout 4% of treatments. Purpura is more likelywhen the 515-nm filter is used or when the pulsedurations are too short, such as coupling a 2.4-mil-lisecond pulse duration with another 2.4-millisec-ond pulse duration. The purpura from IPL isdifferent from typical short-pulse PDL purpura inthat resolution occurs within 2 to 5 days asopposed to the 1- to 2-week purpura seen withPDL treatment.

With the newest progressive set of parameters,the incidence of acute side effects has been mark-edly reduced. Side effects include a mild burningsensation lasting less than 10 minutes noted in45% and erythema, which typically lasts severalhours to 3 days. Mild cheek swelling or edemaoccurs 25% of the time with full face treatmentsprimarily after the initial treatment and lastsfrom 24 to 72 hours. Short-term hyper- or hypo-pigmentation (<2 months) has been noted inapproximately 8 to 15% of sites treated.

Skin Tightening

Wrinkles and skin laxity are structural skin changesthat affect patients physically and emotionally,leading many to seek treatment to achieve a moreyouthful appearance. A variety of technologies,such as dermabrasion and laser resurfacing, havebeen developed to achieve wrinkles reduction,skin tightening, and lifting of sagging skin. Althoughsome of these therapies have demonstrated im-pressive efficacy, their ablative nature has resultedin long recovery periods and postoperative compli-cations,39 which in today’s fast–paced world arenot acceptable to most patients. New nonablativeand noninvasive alternatives are being developedand advanced to safely rejuvenate aging skin with-out downtime. Among the newer nonablative tech-nologies is RF energy (Box 3).

Box 3Ideal system for skin tightening

Low cost

<$1,000 total cost to patient

No disposable costs

Minimal pain

Uniform efficacy

No variability

No adverse effects

Radiofrequency energy produces a thermaleffect when its high-frequency electrical currentflows through the skin. The amount of heat gener-ated in the tissue can be described mathematicallyby Joule’s Law:

H 5 j2/s

where j is the density of the electrical current, ands is the specific electrical conductivity.40 Tissueresistance, or impedance, is inversely proportionalto the electrical conductivity. Based on Joule’sequation, heat is generated as the RF current flowsand encounters resistance in the tissue. The flowof RF energy through biological tissue is a complexprocess that depends on a number of additionalfactors, such as the magnitude and frequency ofthe electrical current and the physical characteris-tics of the target tissue, including its electrolytecontent, hydration level, and temperature. Anothervariable that significantly affects RF energy appli-cations is the distribution of the current appliedto the tissue, which is dependent on the geometryand location of the electrodes used to deliver it, anaspect that is further discussed below.

The use of RF for the treatment of skin texturalalterations in a nonablative manner is becoming in-creasing common due to the vast popularity of op-tical energy–based systems in aesthetic medicine.

An underlying network of collagen and elastinfibers provides scaffolding for the skin and deter-mines its degree of firmness and elasticity. Overtime, this intricate fiber network loosens andunravels, altering the appearance and function ofthe skin. It is estimated that adult skin loses ap-proximately 1% of its dermal collagen content onan annual basis due to increased collagen degra-dation and decreased collagen synthesis.41

When collagen fibers are heated, for exampleusing RF energy, some of the intramolecularcross-links are broken, and unwinding of the triplehelix structure occurs. Beyond a certain level,depending on a combination of the maximal tem-perature and the exposure time, collagen fibersundergo denaturation. When the intermolecularcross-links are maintained, at least partially, colla-gen shrinkage and thickening is achieved.42

Two major electrode configurations (monopolarand bipolar) are available in current RF devices.The energy field created by these electrode con-figurations differs, but the interaction of the emit-ted energy with the targeted tissue is similar. Ina monopolar setting, one electrode emits the RFenergy and the other serves as a grounding pad.The main characteristics of the monopolar config-uration are the high power density on and close tothe electrode’s surface and the relatively deep

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power penetration, which contribute to this config-uration’s suitability for electrosurgery. Due tothese attributes, relatively high pain levels andsome safety concerns may be associated with ap-plying this configuration in dermatology. In a bipo-lar setting, the current flows between two identicalelectrodes that are set at a small fixed distance.This creates a more controlled current distributionin the tissue than with the monopolar setting, butthe depth of penetration is limited to approxi-mately half the distance between the electrodes.As a result, under certain circumstances, lessenergy of sufficient density may reach the deeperskin layers and structures.43

A number of nonablative RF devices, such asThermaCool TC (Thermage, Inc., Hayward, CA),Polaris WR, and Aurora SR (Syneron Medical Ltd.,Yokneam, Israel), have been reported to be safeand effective for the reduction of facial wrinklesand for improvement of the skin’s texture.43–46

ThermaCool TC is based on a monopolar RF elec-trode configuration. Polaris WR uses bipolar RF incombination with a 900-nm diode laser, and AuroraSR consists of the same bipolar RF configurationcombined with IPL. In the two latter devices, thebipolar electrodes are placed flush on top of theskin (Box 4).

Significant dermal collagen contraction and skintightening resulting not only in aesthetically pleas-ing wrinkle reduction but also in lifting of the skin inthe upper (eg, forehead, periorbital region) andlower face (eg, cheeks, jowls, nasolabial folds)have been achieved with ThermaCool TC treat-ment.47–51 Nonsurgical eyebrow, neck, and breastlifting have been demonstrated as a result of treat-ment with this device.49–51 Some tightening effecthas been reported recently using the Polaris WRfor cheek skin laxity.52

The therapeutic gains achieved with some ofthese devices have not been without drawbacks.Significant patient discomfort and difficult-to-manage side effects53,54 have made noninvasive

Box 4Available radiofrequency systems

Thermage Thermacool

Unipolar

Syneron Aurora

Bipolar

Lumenis Aluma

Bipolar vacuum

Cutera Titan

Infrared

treatments with some of the previously developedRF technologies unappealing to a number ofpatients and cosmetic surgeons. The potentialadverse effects with ThermaCool TC have beenreported to be less with recent lower energyprotocols.

Functional Aspiration Controlled ElectrothermalStimulation (FACES) is a more recent implemen-tation of nonablative RF technology that hasbeen incorporated into the device tested in thisstudy. Besides various technical differencesbetween the FACES-based device and the afore-mentioned RF devices, this device is unique in thecombined use of RF with vacuum for the treat-ment of wrinkles and skin laxity. By using vacuumto fold the skin, variable predetermined depths ofthe dermis are placed in close alignment with theRF energy, unlike the constant and larger gapbetween the dermis and the RF energy whenmonopolar or conventional bipolar electrodesare placed on top of the skin surface. By limitingthe volume of treated tissue only to that locatedbetween the two electrodes in the specially de-signed tip, the required energy density can reachand affect the chosen skin layers, whether super-ficial or deep, using lower energy levels.55 Wehave found that nearly 80% of patients expresssatisfaction with their treatment, and investigatorand patients notice at least a 30% improvementin fine lines and wrinkles, which compares favor-ably with other RF devises. Unlike other RFdevises, the Aluma FACES device is relativelypainless. Full face treatments take less than15 minutes and do not require topical or systemicanesthesia. Like all RF skin-tightening proce-dures, multiple treatments increase efficacy withmaximal efficacy noted 3 to 6 months after treat-ment. We are trying to enhance therapeutic effi-cacy by having patients use growth factor andantioxidant creams, which have been demon-strated to further enhance fibroblastic stimulationin producing collagen and elastic fibers to mini-mize wrinkling.56,57

Treatment of Cellulite

Cellulite affects almost all women after puberty,irrespective of age. Over time, this condition getsworse and gives rise to changes in appearanceand resulting psycho-social distress.

The condition presents as dimpling of the skinsurface, ranging from small and sparse to manyand deep dimples, often described as a ‘‘cottagecheese’’ appearance. The dimpling alters the localskin appearance and affects skin texture and over-all body contour. Cellulite mainly affects the hips,thighs, and the inner part of the knee, shoulders


and arms. Less frequently the breast and stomachare affected.58,59

The etiology of cellulite is poorly understood. Agenetic predisposition has been recognized thatis associated with concomitant causes of anendocrine, environmental, postural, and iatrogenicnature.

A number of methods are available for the treat-ment of cellulite, including topical creams andlotions, ultrasound, electrolipolysis, iontophoresis,and mesotherap. None of these has provideslong-term resolution of cellulite. The most success-ful treatments for cellulite seem to be those thatincrease local vascular and lymphatic drainage.

Low-energy lasers have been demonstrated tohave beneficial effects on wound healing and bio-chemical effects on endothelial cells, erythrocytes,and collagen.60 We have evaluated a device witha low-fluence laser and suction massage thatwas developed to reduce the appearance of cellu-lite. This device combines massage with a dynamicsuction action, a low-energy diode laser, and con-tact coolant. The proposed mechanism of actionconsists of increased tissue perfusion, increasedmobilization of lymphatic drainage due to thecombination of dynamic suction massage and

Fig. 3. Triactive J device, showing close-up of treatment hation port, and (c) diode laser emitters. (Courtesy of Cynos

low-level laser irradiation, and reduced tissueedema due to contact cooling (Fig. 3).61

The Triactive device decreased hip and thighcircumference. In addition, blinded evaluatorsfound improvement in appearance of cellulite inall subjects. Treatment was progressive, with animprovement in cellulite over the course of the pro-cedures. Patients enjoyed the procedure andfound it to be relaxing. There were no side effects.

Another study compared the efficacy of treat-ment of cellulite using two novel modalities, TriAc-tive (Cynasure Inc., Westford, Massachusetts)versus VelaSmooth (Syneron Medical Ltd.,Yokneam, Israel).62,63 The VelaSmooth is basedon a combination of two different ranges of elec-tromagnetic energy that produce heat (infraredlight and RF) combined with mechanical manipula-tion of the skin and has been demonstrated to im-prove the appearance of cellulite.

Patients were treated twice a week for 6 weekswith the randomization of TriActive on one sideand VelaSmooth on the other side. There were a to-tal of 12 treatments per leg. In comparing efficacybetween VelaSmooth treatment versus TriActivetreatment, we calculated a 28% versus a 30%improvement, respectively, in the upper thigh

ndpiece. Handpiece includes (a) cooling face, (b) suc-ure Inc., Wesford, MA; with permission.)

Goldman338

circumference measurements, whereas a 56%versus a 37% improvement was observed, re-spectively, in lower thigh circumference measure-ments. These differences in treatment efficacy,using the thigh circumference measurements,were found to be nonsignificant (P > .05).

Based on before and after photographs thatwere blindly evaluated, 25% (5/19) of the subjectsshowed improvement in cellulite appearance forTriActive and VelaSmooth. The average percentimprovement based on random photographygrading from a scale of 1 to 5 (1 representing noimprovement and 5 representing most improve-ment) for the VelaSmooth versus TriActive was7% and 25%, respectively. This difference wasnonsignificant (P 5 .091).

Perceived change grade was calculated basedon random side-by-side comparisons of beforeand after photographs. Seventy-five percent(15/19) subjects showed improvement in theVelaSmooth leg, whereas 55% (11/19) subjectsshowed improvement in the TriActive leg. Theaverage mean percent improvement was roughlythe same for both treatments (22% and 20%, re-spectively) and showed no statistically significantdifference (P > .05).

Bruising was reported in 60% of the subjects.Bruising incidence and intensity was 30% higherin the VelaSmooth leg than in the TriActive leg.Seven out of 20 subjects reported bruising withVelaSmooth, one subject reported bruising withTriActive, and three subjects reported bruisingwith both treatments. Extent of bruising rangedfrom minor purpura to larger and diffused bruisesthat lasted for an average of a week with nointervention.

Our study revealed that both machines effec-tively reduced the appearance of cellulite. Whenusing a P value of 0.05, there was no statisticallysignificant difference between using the TriActiveversus the VelaSmooth in the reduction of cellulite.The TriActive provides low-energy diode laser,contact cooling, suction, and massage, whereasthe VelaSmooth provides a combination of two dif-ferent ranges of electromagnetic energy: infraredlight and RF combined with mechanical manipula-tion of the skin. After twice weekly treatment for6 weeks, there was no statistical significancebetween the two units in upper or lower thighcircumference measurements, randomized photo-graphic evaluations, or perceived change in beforeand after photographic evaluations. Incidence andextent of bruising was higher for VelaSmooth thanTriActive.

Many other devises are being developed andare in use for the treatment of cellulite. It is antici-pated that they will have similar efficacy. There are

no other peer-reviewed clinical studies on thesedevises or comparative studies between thesedevices. The reader should carefully evaluateeach device. The most important point is thatcellulite is not curable and is a normal expressionof fat deposition in women. If a woman wants totemporarily diminish the appearance of cellulite,treatment options conducive to a medical spaare safe, effective, and available.

REFERENCES

1. Goldman MP, Weiss RA, Weiss MA. Intense pulsed

light as a non ablative approach to photoaging.


2. Bitter P Jr, Goldman MP. Non-ablative skin rejuvena-

tion using intense pulsed light. Lasers Surg Med

2000;28(Suppl):12–6.

3. Ross V, Laden Z, Kreindel M, et al. Theoretical

considerations in laser hair removal. Dermatol Clin

1999;17(4):333–55.

4. Anderson R, Parrish J. Selective photothermolysis:-

precise microsurgery by selective absorption of

pulsed radiation. Science 1983;220:524–6.

5. Raulin C, Greve B, Hammes S. Cold air in laser

therapy: first experiences with a new cooling sys-

tem. Lasers Surg Med 2000;27(5):404–10.

6. Eliezri YD. Fifteen month clinical trial of hair removal

with alexandrite laser. Lasers Surg Med 1998;S10:

200.

7. Laughlin SA, Dudley DK. Long-term hair removal

using a 3-millisecond alexandrite laser. J Cutan

Med Surg 2000;4:83–8.

8. Nanni CA, Alster TS. Laser assisted hair removal:

side effects of Q-switched Nd: YAG, long-pulsed

ruby and alexandrite lasers. J Am Acad Dermatol

1999;141:165–71.

9. Grossman MC, Dierickx CC, Quintana A, et al.

Removal of excess body hair with a 800 nm pulsed

diode laser. Lasers Surg Med 1998;S10:201.

10. Lou WW, Quintana AT, Geronemus RG, et al. Pro-

spective study of hair reduction by diode laser

(800nm) with long-term follow-up. Dermatol Surg

2000;26:428–32.

11. Tanzi EL, Alster TS. Long-pulsed 1064-nm Nd:YAG

laser-assisted hair removal in all skin types. Derma-

tol Surg 2004;30:13–7.

12. Alster TS, Lupton JS, Russo ML. Clinical and histo-

logic efficacy of depilase long-pulsed Nd-YAG laser

for hair removal in dark skin phototypes. Lasers Surg

Med 2001;S13:196.

13. Raff K, Landthaler M, Hohenleutner U. Optimizing

treatment parameters for hair removal using long-

pulsed Nd:YAG lasers. Lasers in Medical Science

2004;18:219–22.

14. Ross EV, Cooke LM, Timko AL, et al. Treatment of

pseudofolliculitis barbae in skin types IV, V, and VI


with a long-pulsed neodymium:yttrium aluminum

garnet laser. J Am Acad Dermatol 2002;47(2):

263–70.

15. Fodor L, Menachem M, Ramon Y, et al. Hair removal

using intense pulsed light (EpiLight): patient satis-

faction, our experience, and literature review. Ann

Plast Surg 2005;54(1):8–14.

16. Bedewi AF. Hair removal with intense pulsed light.

Lasers Med Sci 2004;19(1):48–51.

17. Sadick NS, Shaoul J. Hair removal using a combina-

tion of conducted radiofrequency and optical

energies–an 18-month follow-up. J Cosmet Laser

Ther 2004;6(1):21–6.

18. Divaris DXG, Kennedy JC, Poittier RH.

Phototoxic damage to sebaceous glands and hair

follicles of mice after systemic administration of

5-aminolevulinic acid correlates with localized

protoporphyrin IX fluorescence. Am J Pathol 1990;

136:891–7.

19. Bouzari N, Tabatabai H, Abbasi Z, et al. Laser hair

removal: comparison of long-pulsed Nd:YAG, long-

pulsed alexandrite, and long-pulsed diode lasers.

Dermatol Surg 2004;230:498–502.

20. Handrick C, Alster TS. Comparison of long-pulsed

diode and long-pulsed alexandrite lasers for hair

removal: a long-term clinical and histologic study.

Dermatol Surg 2001;27(7):622–6.

21. Galadari I. Comparative evaluation of different hair

removal lasers in skin types IV, V, and VI. Int

J Dermatol 2003;42(1):68–70.

22. Rao J, Goldman MP. A prospective, comparative

evaluation of three laser systems used individually

and in combination for axillary hair removal. Derma-

tol Surg 2005;31:1671–7.

23. Khoury JG, Saluja M, Goldman MP. Comparative

evaluation of long-pulse alexandrite and long-pulse

1064 nm Nd:YAG laser systems used Individually

and in combination and 810 nm diode laser for

axillary hair removal. Dermatol Surg 2008, in press.

24. Goldman MP, Eckhouse S. Photothermal sclerosis of

leg veins. ESC Medical Systems, LTD Photoderm VL

Cooperative Study Group. Dermatol Surg 1996;

22(4):323–30 [see comments].

25. Green D. Photothermal sclerosis of leg veins.

Dermatol Surg 1997;23(4):303–5 [letter; comment].

26. Bitter PH. Noninvasive rejuvenation of photodam-

aged skin using serial, full-face intense pulsed light

treatments. Dermatol Surg 2000;26(9):835–42.

27. Weiss RA, Weiss MA, Beasley KL, et al. Rejuvenation

of photoaged skin: 5 yr results with IPL. Dermatol Surg

2002;28:1115.

28. Weiss RA, Goldman MP, Weiss MA. Treatment of

poikiloderma of Civatte with an intense pulsed light

source. Dermatol Surg 2000;26(9):823–7.

29. Zelickson B, Kist D. Pulsed dye laser and photo-

derm treatment stimulates production of type-I

collagen and collagenase transcripts in papillary

dermis fibroblasts. Lasers Surg Med 2001;13:33

[abstract supplement].

30. Zelickson B, Kist D. Effect of pulse dye laser and

intense pulsed light source on the dermal extracellu-

lar matrix remodeling. Lasers Surg Med 2000;12:17

[abstract supplement].

31. Hernandez-Perez E, Ibiett EV. Gross and micro-

scopic findings in patients submitted to nonablative

full face resurfacing using intense pulsed light.


32. Negishi K, Wakamatsu S, Kushikata N, et al. Full-

face photorejuvenation of photodamaged skin by

intense pulsed light with integrated contact cooling.

Lasers Surg Med 2002;30:298–305.

33. Troilius A, Bjerring P, Dierickx C, et al. Photorejuve-

nation with a double exposure procedure using

a new IPL system. Lasers Surg Med 2002;(Suppl

14):29.

34. Nootheti PK, Pettit KA, Yosowitz G, et al. Clinical

improvement of photodamaged skin after a single

intense pulsed light treatment. American Journal of

Cosmetic Surgery 2007;24:15–20.

35. Ruiz- Rodriguez R, San-Sanchez T, Cordoba S. Pho-

todynamic photorejuvenation. Dermatol Surg 2002;

28:742–4.

36. Avram DK, Goldman MP. Effectiveness and safety of

ALA-IPL in treating actinic keratoses and photodam-

age. J Drugs Dermatol 2004;3(1 Suppl):S36–9.

37. Nootheti PK, Goldman MP. Aminolevulinic acid-

photodynamic therapy for photorejuvenation. Der-

matol Clin 2007;25:35–45.

38. Gold MH, Goldman MP. ALA-PDT: where we have

been and where will we are going. Dermatol Surg

2004;30:1077–84.

39. Nanni CA, Alster TS. Complications of carbon

dioxide laser resurfacing: an evaluation of 500 pa-

tients. Dermatol Surg 1998;24:315–20.

40. Gabriel S, Lau RW, Gabriel C. The dielectric proper-

ties of biological tissues: III. Parametric models for

the dielectric spectrum of tissues. Phys Med Biol

1996;41:2271–93.

41. Chung J, Cho S, Kang S, et al. Why does the skin

age? Intrinsic aging, photoaging, and their patho-

physiology. In: Rigel DS, Weiss RA, Lim HW, editors.

Photoaging. New York: Marcel Dekker, Inc.; 2004. p.

1–15.

42. Arnoczky SP, Aksan A. Thermal modification of con-

nective tissues: basic science considerations and

clinical implications. J Am Acad Orthop Surg 2000;

8(5):305–13.

43. Sadick NS, Makino Y. Selective electro-thermolysis

in aesthetic medicine: a review. Lasers Surg Med

2004;34(2):91–7.

44. Ruiz-Esparza J, Gomez JB. The medical face lift:

a noninvasive, nonsurgical approach to tissue tight-

ening in facial skin using nonablative radiofre-

quency. Dermatol Surg 2003;29(4):325–32.

Goldman340

45. Sadick NS, Trelles MA. Nonablative wrinkle treat-

ment of the face and neck using a combined diode

laser and radiofrequency technology. Dermatol Surg

2005;31(12):1695–9.

46. Bitter P Jr, Mulholland S. Report of a new technique

for enhanced non–invasive skin rejuvenation using

a dual mode pulsed light and radio-frequency

energy source: selective radiothermolysis. J Cosmet

Dermatol 2002;1:142–3.

47. Iyer S, Suthamjariya K, Fitzpatrick RE. Using a radio-

frequency energy device to treat the lower face:

a treatment paradigm for a non-surgical facelift.

Cosmetic Dermatology 2003;16(2):37–40.

48. Ruiz-Esparza J, Barba-Gomez J. Non-ablative

radiofrequency tissue tightening of facial skin: the

medical face lift: a report of 25 patients. Lasers

Surg Med 2003;15:36.

49. Alster TS, Tansi E. Improvement of neck and cheek

laxity with a non-ablative radiofrequency device:

a lifting experience. Dermatol Surg 2004;30:503–7.

50. Fitzpatrick R, Geronemus R, Goldberg D, et al.

Multicenter study of noninvasive radiofrequency for

periorbital tissue tightening. Lasers Surg Med

2003;33(4):232–42.

51. Ruiz-Esparza J, Barba-Gomez J. The non-invasive,

non-surgical breast lift radiothermopexy: tissue

tightening via non-ablative radiofrequency. Lasers

Surg Med 2003;15:36.

52. Doshi SN, Alster TS. Combination radiofrequency

and diode laser for treatment of facial rhytides and

skin laxity. J Cosmet Laser Ther 2005;7(1):11–5.

53. Ruiz-Esparza J. A less painful, faster and safer

application of non-ablative radiofrequency. Lasers

Surg Med 2004;16:28.

54. Ruiz-Esparza J. Non-invasive skin tightening induced

by radiofrequency and infrared light devices. In:

Goldman MP, editor. Cutaneous and cosmetic laser sur-

gery. New York: Elsevier Science Publishing, Inc.; 2006.

p. 325–48.

55. Gold MH, Goldman MP, Rao J, et al. Treatment of

wrinkles and skin tightening using vacuum–assisted

bipolar radiofrequency heating of the dermis. Der-

matol Surg 2007;33:300–9.

56. Ehrlich M, Rao J, Pabby A, et al. Improvement in the

appearance of wrinkles with topical transforming

growth factor b1 and L-ascorbic acid. Dermatol

Surg 2006;32:618–25.

57. Hsu J, Skover G, Goldman MP. Evaluating the

efficacy in improving facial photodamage with a mix-

ture of topical antioxidants. J Drugs Dermatol 2007;

6:1139–46.

58. Hexsel D, et al. Social impact of cellulite and its impact

on quality of life. In: Goldman MP, Hexsel D, Bacci PA,

editors. Cellulite; pathophysiology and treatment.

New York: Taylor & Francis; 2006. p. 1–5.

59. Rao J, Goldman MP. A double-blinded randomized

trial testing the tolerability and efficacy of a novel

topical agent with and without occlusion for the

treatment of cellulite: a study and review of the

literature. J Drugs Dermatol 2004;3:417–27.

60. Boyce S, Pabby A, Chuchaltkaren P, et al. Clinical

evaluation of a device for the treatment of cellulite:

Triactive. The American Journal of Cosmetic Surgery

2005;22(4):233–7.

61. Nootheti PK, Magpantay A, Yosowitz G, et al. A single

center, randomized, comparative, prospective clini-

cal study to determine the efficacy of the Velasmooth

system versus the Triactive system for the treatment of

cellulite. Lasers Surg Med 2006;38:908–12.

62. Alster T, Tanzi EL. Extended experience with a novel

combination radiofrequency, infrared light and me-

chanical tissue manipulation device for the treatment

of cellulite. J Cosmet Laser Ther 2005;7:81–5.

63. Sadick NS, Mulholland RS. A prospective clinical

study to evaluate the efficacy and safety of cellulite

treatment using the combination of optical and RF

energies for subcutaneous tissue heating. J Cosmet

Laser Ther 2004;6:187–90.

Procedures Offeredin the Medical SpaEnvironment
Amy F.Taub, MD
KEYWORDS� Medical spa treatments � Medical spa devices� Laser devices � Spa equipment � Aesthetic treatments

There are several types of medical spas which in-clude: those that are individually run and owned bya physician; those that are owned by entrepreneurwith physician as medical director (either on or offsite and in single versus multiple locations); thoseowned by an entrepreneur, with physician as med-ical director off-site (single versus multiple outlets);and those owned by physician with multiple sites.

Typical core services at most medical spas in-clude: microdermabrasion, medical facials, chem-ical peels, botulinum toxin, injectable fillers, hairremoval, and photorejuvenation. Common proce-dures include: cellulite reduction, body shaping,tissue tightening, mesotherapy, and acne therapy.Less common medical services include: fractionalresurfacing, erbium resurfacing, sclerotherapy orlaser leg vein treatments, photodynamic therapy,tattoo removal, laser-assisted lipoplasty, musclestimulation devices, liposuction, cosmetic surgery(eg, blephroplasty, rhytidectomy, brow lift), acu-puncture, and LED treatments. Less commonspa services include: massages, body wraps,manicure/pedicure services, smoking cessation,and nutritional guidance (Table 1).

Typically, the closer the on-site involvement witha physician, the more likely ‘‘aggressive’’ proce-dures, such as laser resurfacing, liposuction,cosmetic surgery, sclerotherapy or laser-assistedlipoplasty, are used.

m

TYPES OF LASER EQUIPMENT USEDBYMEDICAL SPAS

Many medical spas use ‘‘multiplatform’’ devices.These are typically one box with multiple

Advanced Dermatology, Skinfo and SKINQRI, 275 ParkwE-mail address: [email protected]


handpieces that can perform many different pro-cedures. This is different from using individuallasers or light devices that specialize in one ora few applications. There is no definite superiorityto the multiplatform devices, but most establishedmedical spas which have close involvement ofa medical director have multiplatform devices inaddition to individual devices. This is optimal forpatients because there is some variation in howpatients respond to various devices. In medicalspas with multiple sites, using multiplatformdevices makes training easier as well as providinga uniformity of services. Additionally, multiplatformuse probably reflects a financial incentive for theprovider.

CORE SERVICESMicrodermabrasion

Microdermabrasion has been a mainstay of‘‘esthetician-based’’ adjunctive care for most cos-metically oriented dermatologists and plasticsurgeons for many years. It debuted as a crystal-based aluminum oxide closed loop system in themid-1990s. Microdermabrasion provided a wayto superficially abrade the epidermis and itachieved improvement in scars, superficial skindamage, and pores.1

Microdermabrasion has been studied histologi-cally as well as with respect to the function of theepidermis. Chronic histopathologic effects wereexamined in three volunteers who underwentskin biopsies before and after a treatment serieson the dorsal forearms.2 By patient assessment,there was statistically significant improvement inroughness, mottled pigmentation, and overall

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Table1Procedures offered in medical spas

Core Services Common Procedures Less CommonMedical ProceduresLess CommonSpa Services

Microdermabrasion Cellulite reduction Fractional resurfacing Massages

Medical facials Body shaping Resurfacing Body wraps

Chemical peels Tissue tightening Sclerotherapy Manicure/Pedicure

Botulinum toxin Mesotherapy Laser leg vein Smoking cessation

Injectable fillers Acne therapy Photodynamic therapy (PDT) Nutritional guidance

Hair removal Tattoo removal

Photorejuvenation Laser-assisted lipoplasty

Muscle stimulation devices

Liposuction

Cosmetic surgery

Acupuncture

LED

Taub342

improvement of skin appearance, but not in rhyti-des. Acne scarring sometimes improved, but re-quired deeper ablation. Acutely, the stratumcorneum was homogenized and focally com-pacted. Chronically, there was epidermal hyper-plasia, decreased melanization, and someincrease in elastin. These changes demonstratedthat there were some measurable effects on signsof photo aging and surface topology. Grimes andcolleagues demonstrated that both aluminum car-bonate and sodium chloride-based microdermab-rasion initially decreased transepidermal waterloss (TEWL) but then resulted in increasedhydration after 24 hours or one week. They con-cluded that the alteration in epidermal functionwas most likely responsible for the effects seenwith this technique.3 Another study revealed thatmicrodermabrasion resulted in the following histo-logic changes: thickening of the epidermis anddermis, flattening of the rete pegs, vascular ecta-sia and perivascular inflammation, and hyaliniza-tion of the papillary dermis with newly depositedcollagen and elastic fibers.4 The authors sug-gested that microdermabrasion produces clinicalimprovement by a mechanism resembling a repar-ative process at the dermal and epidermal levels.There are hundreds of different microdermabra-sion machines on the market. These include alumi-num oxide, sodium chloride particle-basedsystems, and units that use ultrasound and eitherwater, diamond or other rough materials in addi-tion to suction (Table 2). These machines alsoare used to improve the penetration of topicalactives, such as aminolevulinic acid5 or vitamin C.6

The FDA has classified microdermabrasion unitsas Class 1 medical devices. As such, the machines

can be sold without demonstration of clinicalefficacy. Additionally, they can be operated withoutmedical supervision, as long as the procedure onlyremoves the stratum corneum and does not affectthe skin’s structure or function.7 They are some-times categorized as ‘‘spa’’ and ‘‘medical’’ devicesbased on how aggressively the procedure can pen-etrate the epidermis. There is a wide variation in thetraining of providers for this procedure. Aggressiveprocedures can cause excessive exfoliation, in-creased redness or rosacea, and dermatitis flares.

According to the American Society of PlasticSurgeons, microdermabrasion is the fourth mostpopular non-surgical procedure with 1,023,931procedures performed in 2005, a decrease of 7%from 2004.8

Chemical Peels

Chemical peels performed in the medical spa areusually of the superficial or ‘‘lunch-time’’ variety.Three types of chemical peels are available withterms based on the depth of the peel: superficial,medium, and deep. Chemical peels are typicallyused for: the treatment of acne or enlarged pores,for melasma, for anti-aging, and to enhance theresults of other aesthetic interventions, such aslaser treatments.9 Mild chemical peels have alsobeen popular for treating type V and type VI skin,due to their efficacy and safety.10

A variety of mild chemical peels are availableincluding: glycolic acid, trichloroacetic (TCA)acid, Jessner’s solution (14% lactic acid, 14%resorcinol, and 14% salicylic acid), salicylic acid,pyruvic acid, and resorcinol preparations.11 Reti-noic and lactic acid are other agents used.

Table 2Microdermabrasion devices

Device Supplier Type

Esprit Aesthetic technologies Aluminum oxide crystals

Prestige Aesthetic technologies Aluminum oxide crystals

Esprit duette Aesthetic technologies Aluminum oxide crystals orcrystal-free diamond tip

Prestige duette Aesthetic technologies Aluminum oxide crystals orcrystal-free diamond tip

DermaSweep Cosmetic R & D, Inc. Particle-free, nylon bristles

DermaSweep mini Cosmetic R & D, Inc. Particle-free, nylon bristles

MegaPeel platinum DermaMed international Aluminum oxide and sodiumbicarbonate crystals or crystal-freediamond tip

Megapeel gold DermaMed international Aluminum oxide and sodiumbicarbonate crystals orcrystal-free diamond tip

MegaPeel silver DermaMed international Aluminum oxide and sodiumbicarbonate crystals orcrystal-free diamond tip

Delphia Edge systems Aluminum oxide and sodiumbicarbonate crystals

Delphia IIe plus Edge systems Aluminum oxide and sodiumbicarbonate crystals orcrystal-free diamond tip

Dephia del sol plus LED Edge systems Aluminum oxide and sodiumbicarbonate crystals orcrystal-free diamond tip and bluelight or red light LED

Diamond delphia Edge systems Crystal-free diamond tip

AestiLISSE Lumenis Aluminum oxide crystals or crystal-freediamond tip

Aesthipeel Mattioli engineering Corundum powder

Ultrapeel pepita Mattioli engineering Corundum powder

Ultrapeel crystal Mattioli engineering Corundum powder

Ultrapeel II Mattioli engineering Corundum powder

Gemini Science innovative aesthetics Fine crystal all natural organic grain

Aurora Science innovative aesthetics Crystal-free diamond tip

SkinBella Sybaritic, Inc. Ultrasound

Libra Syneron corundum crystals

Pristine Viora crystal free diamond tip

Adapted from Aesthetic Buyers Guide, July/August 2007.

Procedures Offered in the Medical Spa Environment 343

Both lactic acid and Jessner’s were found tobe effective treatments for epidermal melasma.12

In another study of type IV–V skin patients,the addition of chemical peels (6 glycolicpeels, 30%–40%) with a topical formulation(2% hydroquinone, 1% hydrocortisone and0.05% tretinoin) showed a statistically signifi-cant improvement of melasma over thosepatients who were treated with topical therapyalone.13

One study showed that 70% glycolic acid andJessner’s peels were equally efficacious for thetreatment of acne, but Jessner’s peels resulted inmuch more exfoliation. Thus, the authors recom-mended usage of glycolic acid. However, treat-ment with glycolic acid (70%) is much moredifficult technically and it may result in complica-tions that could be considered severe.14

A study of right-left comparison of Asian skin in10 patients showed similar and statistically

Taub344

significant improvement of melasma with 1% reti-noic acid peels versus 70% glycolic acid.15 Astudy of 30% salicylic acid peels showed thatthey improved photodamage and skin rough-ness.16 In a comparison study of 70% glycolicacid and 35% TCA, both peels demonstratedsimilar levels of improvements in papillary dermalproteins, with only TCA showing epidermal necro-sis and both showing histologic changes that lastabout 2 years.17 In a study of 35 Korean patientswith acne who received biweekly treatments with30% salicylic acid, a significant decrease inCunliffe acne score was found to be correlatedwith duration of therapy.18 Eighty patients receiv-ing 8–10 treatments of 70% glycolic acid foundimprovements in comedonal, papulopustular andnodulocystic acne as well as post-acne scarsand pigmentation.19

Most medical spas use estheticians or nurses forthe administration of mild chemical peels. Peelsthat are considered mild would be those with20%–30% glycolic acid, 20%–30% salicylic acid,Jessner’s solution, and up to 30% lactic acid. Themild category might also include 10%–20% TCApeels. The more moderate to deep chemical peels,such as glycolic acid 70%, TCA >30%, lactic acid>35%, should be administered by a physician orunder the direct supervision of a physician.

Medical Facials

Medical facials could be defined as facials whoseprimary goal is to effect an improvement in thecondition of the skin rather than deep cleansingand relaxation.

A facial could be considered the most basic ofaesthetic services. Typcially provided in relaxationfocused spas (as opposed to medical spas) andday spas, as well as in some beauty salons thathave extended their services, facials are usuallycomprised of deep cleansing, skin analysis (byan esthetician who examines the skin with a magni-fying lens), exfoliation (often with steam), extrac-tions, massage, a mask (targeted to the client’sskin type), and application of moisturizer. Oftenthe esthetician will provide advice on home skincare and offer products for purchase.20

The requirements for estheticians and cosme-tologists vary by state. In Illinois, the requirementfor education is 1500 hours for a cosmetologistand 750 hours for an esthetician.21 Cosmetologycurricula usually encompass the study of hair styl-ing, skin care, nail care, and make-up. Estheticscourses typically focus on make-up application,facials, massage, and waxing.

Medical facials often focus on specific problemssuch as aging skin, large pores or acne, maintenance

of skin with rosacea, hydration, or a combination ofthese conditions. Medical facials often use physi-cian-dispensed products and a method of penetra-tion that allows the ingredients to penetrate moredeeply into the dermis to enhance the effects. Variousmethods for penetration may be used: stratum cor-neum removal with either chemical agents or micro-dermabrasion; ultrasonic devices that use heat and/or ultrasound; or suction and sponges (prototypedevice, Aesthera, Pleasanton, CA). The goals of thesefacials may include optimal dermal moisture, antioxi-dant penetration, reduction in lines or wrinkles,improved skin elasticity, reduced hyperpigmentation,and overall improvement of skin color, texture,and tone.

While permanent results are not realistic withthese mild treatments, the treatments should beconsidered to maintain and improve daily skincare regimens as well as being appropriate asadjuncts to laser or other procedures. In addition,the treatments provide an entry-level service forpatients/clients who may not be ready for ‘‘inject-ables’’ or laser procedures.

Botulinum Toxin

Botulinum toxin A (BOTOX, Allergan, Irvine, CA) isa purified complex of the neurotoxin producedfrom the bacterium Clostridium botulinum. In themid-1980s, clinical reports began to emergeregarding the therapeutic effects of botulinum toxinin blepharospasm and strabismus22–26 and, in1989, the FDA approved BOTOX for these indica-tions. In 1992, the first published cosmetic studyreported that 16 of 17 subjects had a markedimprovement of glabellar wrinkles after BOTOXinjections into the corrugators or brow furrowsand the result lasted 3–11 months.27 In April 2002,BOTOX Cosmetic was granted FDA approval forthe treatment of moderate to severe frown lines ofthe glabella. It is used off-label in other areasof the face for cosmetic benefit as well. Injectionof BOTOX Cosmetic has become the most com-monly performed cosmetic procedure with over3 million injections performed in 2006.28

Performing treatments with BOTOX Cosmeticrequires a strong knowledge of the anatomy andfunction of the muscles in the treatment area.29

Only dynamic wrinkles that are caused or wors-ened by muscle movement or expression can beexpected to improve with treatment. The mostcommon area treated is the upper third of theface including: crow’s feet around the eyes; frownlines between the brow; and transverse linesacross the forehead. Highly experienced providersalso treat vertical lines of the upper lip, platysmalbands, dimpling of the chin, muscles exacerbating


the marionette lines, and other areas of the lowerface. BOTOX Cosmetic should not be performedon patients who have neuromuscular junctionaldisorders, such as multiple sclerosis, myastheniagravis, or Lambert-Eaton syndrome.

The FDA has warned consumers that, despite itsname, BOTOX Cosmetic is a drug and not a cos-metic. They go on to say: ‘‘increasingly, the word‘cosmetic’ is being used as a medical term to de-scribe a number of surgical and non-surgical treat-ments that are intended to enhance appearanceand are performed only by a licensed healthcareprofessional. BOTOX Cosmetic is one such treat-ment.’’30 Only those medical spas that use physi-cians or licensed health care providers underphysician supervision are following FDA policies.

Unwanted local effects of the botulinum toxin aregenerally transient. As with any injection, pain, bruis-ing and infection can occur. The most common sideeffects—aside from bruising—include asymmetry,headache, and pronounced lateral eyebrow eleva-tion (‘‘Spock’’ eyes). Brow and eyelid ptosis aremore severe side effects, which occur in less than1%of injections andare usually related to technique.

Injectable Fillers

Injectable wrinkle fillers have experienced a hugeincrease in popularity with over 1.5 million

Table 3Injectable fillers

Filler Supplier

Silikon 1000 Alcon laboratories

Zyderm Allergan/Inamed

Zyplast Allergan/Inamed

CosmoDerm Allergan/Inamed

CosmoPlast Allergan/Inamed

Juvederm Allergan/Inamed

Artefill Artes medical

Radiesse BioForm

Sculptra Dermik/Aventis

Fascian Fascia biosystems

FG-5017 FibroGen

Restylane Medicis

Perlane Medicis

Puragen Mentor corp

Prevelle Mentor corp

Belotero Merz pharma

HylaNew Prollenium medical technologie

Teosyal Teoxane SA


hyaluronic acid procedures performed in 2006.28

This is probably attributed to the advent of safer,longer-lasting agents, as well as to the increasingacceptance of and the recognition of the signifi-cant enhancements that are able to be realizedwith these procedures.

FDA-approved fillers include: hyaluronic acids(Restylane and Perlane, Medicis, Scottsdale, AZ;Juvederm, Allergan, Irvine, CA; Captique and Hy-laform, Inamed, Fremont, CA), collagen-basedmaterials (Cosmoderm, Cosmoplast, Zyderm andZyplast, Inamed, Fremont, CA), calcium hydroxyl-apatite (Radiesse, BioForm Medical, San Mateo,CA),31 and poly-L-lactic acid (Sculptra, Dermik,Berwyn, PA) (Table 3).32 All fillers except Sculptraare approved for nasolabial fold enhancementwhereas Sculptra is approved for correction of lip-oatrophy in HIV-infected individuals. However,these injection fillers are widely used off-label forother procedures such as lip augmentation, browelevation, marionette line correction, cheek en-hancements, and overall volume improvement.33

The injection of fillers requires an artistic aes-thetic sensibility, excellent eye-hand coordination,and an intimate knowledge of facial anatomy.The necessary skills are difficult to obtain andrequire much experience. Injectable fillers arerecommended for use by experienced dermasur-geons or by physician assistants or nurse

Type

Silicone

Bovine collagen

Bovine collagen

Human-based collagen

Human-based collagen

Hyaluronic acid

20% polymethylmethacrylate (PMMA)

Calcium hydroxylapatite

Poly-L-Lactic acid

Fascia

Human collagen

Hyaluronic acid

Hyaluronic acid

Hyaluronic acid

Hyaluronic acid

Hyaluronic acid

s Hyaluronic acid

Hyaluronic acid

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practitioners who are under the close supervisionof a dermasurgeon.

Hair Removal

Lasers are approved for permanent hair reduction.The FDA defines this as ‘‘long-term stable reduc-tion in the number of hairs regrowing after a treat-ment regime.’’34

Laser hair removal first became available in themid-1990s. As with almost all laser technology,laser hair removal is based on the idea of selectivephotothermolysis.35 In this case, the goal is to heatand destroy the follicular unit without damagingthe surrounding tissue. The target chromophoreis melanin in the hair follicle. The amount ofmelanin in hair and skin varies widely between in-dividuals. Therefore, it is crucial to select theappropriate wavelength, spot size, and pulseduration based on the patient’s skin type andhair color for efficacy and safety. The first laserswere only effective for light-skinned and dark-haired patients. Advances in technology hasallowed for safe treatments in darker-skinned pa-tients and those with lighter-colored hair (Table 4).

RubyThe ruby laser (694 nm) was the first laser widelyused for hair removal.36,37 Although it was effec-tive in lighter-skinned patients, it is not used fre-quently today.

AlexandriteThe alexandrite laser (755 nm) was introducedshortly after the ruby and is still used frequentlytoday. Its longer wavelength allowed for deeperpenetration and it could cautiously be used to treatsome darker-skinned patients.38 Studies havereported hair reduction up to 50% after only a sin-gle treatment; and up to 95% hair reduction aftermultiple treatments, depending upon number oftreatments and body location.39–41

DiodeTreatment of unwanted hair with the diode laser(810 nm) has been demonstrated as comparableto those of the ruby or alexandrite lasers. Aftera single treatment, hair reductions of about 30%have been reported; and up to 84% hair reductionhas been reported after multiple treatments.42,43

The diode laser can also be used cautiously indarker-skinned patients due to its longerwavelength.

Nd:YAGThe Nd:YAG laser (1064 nm) is the safest typeused to treat unwanted hair on patients with darkskin, but the laser does not provide an optimalwavelength for hair removal. Results can be

achieved, but higher energies are necessary toachieve results due to the lesser affinity with mel-anin. Reports have shown improvement of about50%, depending on the number of treatmentsadministered and the body location.44

Intense pulsed lightIntense pulsed light (IPL) systems have wave-lengths from 550–1200 nm, in contrast to laserlight sources, which produce monochromatic lightof a specific wavelength. In IPL devices, filters areused to cut off lower wavelengths and the laserscan be set to varying wavelengths. In a study of210 patients who had hair removal treatmentswith IPL, a mean hair reduction of 80% was re-ported with five treatments.45

Intense pulsed light and radio frequencyEl�os technology, combining either IPL or diodelaser with bipolar radiofrequency (RF), is themost recent advancement in laser hair removal.In this dual energy treatment, the hair follicle ispreheated by light or laser, and then, RF causesfurther injury. Because RF does not require a chro-mophore target, this was the first technology thatstudies have shown to be effective at treatinglight-colored hair, including white.46,47 Theefficacy is lower when treating light-colored hair,however.

The number of treatments necessary and the in-terval between treatments depends upon the areaof the body being treated. Only hair in the anagenor growing phase is able to be effectively treated.Hair in the telogen (ie, resting phase) or catagen(ie, the phase between anagen and telogen) doesnot have a mature enough follicle to be effectivelytreated. The length of time spent in each phase de-pends upon the location of the hair. On the scalp,hair follicles spend up to 10 years in anagen, buton the trunk, brow, and limbs, anagen lasts no lon-ger than 6 months. Catagen lasts only 2–3 weeks,and telogen lasts from 3–4 months.48 Explainingthe need for multiple treatments, the correct timingof treatments and the inability to remove hair100% help achieve good results and maintainpatient satisfaction.

Photorejuvenation

Many lasers and light sources have been devel-oped with the idea of simultaneously removingunwanted epidermal pigmentation and reducingupper dermal telengiectasia, thus overall improv-ing the texture and tone of the skin (Table 5). Itwas noted by a number of investigators that thesemodalities also seemed to improve superficialwrinkles and to cause some skin smoothing andtightening.

Table 4Laser hair removal devices


LightPod neo Aerolase Nd:YAG

Soprano XL Alma lasers CW Diode

Harmony Alma lasers AFT pulsed light

GentleLASE Candela Alexandrite

GentleYAG Candela Nd:YAG

GentleMax Candela Alexandrite/Nd:YAG

VARIA CoolTouch Nd:YAG

CoolGlide CV Cutera Nd:YAG

Prowave Cutera Infrared

Apogee Cynosure Alexandrite

Elite Cynosure Alexandrite/Nd:YAG

Acclaim Cynosure Nd:YAG

PhotoSilk plus Cynosure XE Lamp

Cynosure PL Cynosure Pulsed light

Quadra Q4 DermaMed international Intense pulsed light

DermaYag DermaMed international Nd:YAG

NaturaLase LP Focus medical Nd:YAG

NaturaLight Focus medical Pulsed light

RevLite HOYA ConBio EO Q-switched Nd:YAG with photoacoustictherapy pulse (PTP) technology

MedLite C6 HOYA ConBio EO Q-switched Nd:YAG

LightSheer Lumenis Diode

IPL Quantum Lumenis Intense pulsed light

Lumenis One Lumenis Nd:YAG

Elora Lumenis Intense pulsed light

Asclepion MeDioStar XT MedSurge Advances Diode

Milesman premium Milesman Diode

Clareon HR Novalis Pulsed light

Solarus HR Novalis Pulsed light

Starlux Palomar Pulsed light

SkinStation Radiancy LHE (light and heat energy)

Duet Radiancy LHE (light and heat energy)

SpaTouch pro Radiancy LHE (light and heat energy)

ClearScan Sciton Nd:YAG

Profile HMV Sciton Nd:YAG and pulsed light

NannoLight Sybaritic Pulsed light

SpectraQuattro Sybaritic Pulsed light

eLaser DSL Syneron Diode/RF

eLight DS Syneron Optical energy/RF



Pulsed dye laserAs the first laser developed to apply the principleof selective photothermolysis, the pulsed dye laser(PDL), 585 nm, remains the gold standard for thetreatment of vascular lesions.49 Zelickson and

colleagues50 reported the first investigation ofPDL for the treatment of sun-induced facial rhy-tids. Histologic examination revealed dermalchanges consistent with collagen remodeling.These results were confirmed in 2000 by Bjerring

Table 5Photorejuvenation devices


LightPod neo Aerolase Nd:YAG

Harmony Alma lasers AFT pulsed light, Near-infrared, Nd:YAG

Vbeam Candela Pulsed dye

GentleYAG Candela Nd:YAG

CT3 plus CoolTouch Nd:YAG

CoolGlide vantage Cutera Nd:YAG

Xeo Cutera Intense pulsed light

Limelight Cutera Intense pulsed light

Acclaim Cynosure Nd:YAG

Cynosure PL Cynosure Pulsed light

Elite Cynosure Alexandrite, Nd:YAG

Cynergy Cynosure Pulsed dye, Nd:YAG, Intense pulsed light


NaturaLight Focus medical Pulsed light, Nd:YAG

RevLite HOYA conbio EO Q-switched Nd:YAG with photoacoustictherapy pulse (PTP) technology

MedLite HOYA conbio EO Q-switched Nd:YAG

VariLite Iridex KTP/Diode

DioLite Iridex KTP

Velure S5 Lasering Diode

GentleWaves Light bioscience LED

Elora Lumenis Intense pulsed light

IPL Quantum SR Lumenis Intense pulsed light

Lumenis One Lumenis Intense pulsed light, Nd:YAG, Diode,Aluma RF

Spectra Lutronic Q-switched Nd:YAG

Quantel medical prolite II MedSurge advances Intense pulsed light

Clareon SR Novalis Pulsed light

Solarus SR Novalis Pulsed light

StarLux LuxG handpiece Palomar Pulsed light

OmniLux Photo therapeutics LED

Ultrawave Quanta system Nd:YAG, KTP, Alexandrite

Eterna Quanta system Intense pulsed light

PROLITE II Quantel medical Intense pulsed light


Duet Radiancy LHE (light and heat energy)

SPR Radiancy LHE (light and heat energy)

Facial skincare device Radiancy LHE (light and heat energy)

ClearScan/ThermaScan Sciton Nd:YAG

BBL Sciton Pulsed light

Profile HMV Sciton Nd:YAG, Pulsed light


SkinClear Sybaritic Q-switched Nd:YAG


eLight SR and SRA Syneron Optical energy, RF


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and colleagues51 who, by altering the pulse dura-tion, obtained cosmetic improvement without pur-pura. Tanghetti and colleagues52 reported similarclinical improvement in facial dyspigmentationand wrinkling after single-pass and double-passtreatment with either 585 nm or 595 nm. In a con-trolled, split-face study, Hsu and colleagues53

reported improvements in surface topography of9.8% (one treatment) and 15% (two treatments)supported by histologic evidence of collagenremodeling.

Intense pulsed lightGenerally considered the gold standard for thenonablative treatment of superficial photodamage,intense pulsed light (IPL) achieves selective photo-thermolysis with non-coherent polychromatic light(w500 nm to w1200 nm). Due to the broad spec-trum of visible light, the two main chromophores,hemoglobin and melanin, can be effectively tar-geted with only one piece of technology. The min-imal risk and downtime associated with thisprocedure have contributed to its success.54

Two key studies were reported in 2000. Bitter55

showed that serial treatments with IPL visibly im-proved wrinkling, irregular pigmentation, skincoarseness, pore size, and telangiectasias inmore than 90% of patients with little downtime.The patient satisfaction rate exceeded 88%. Gold-berg and Cutler56 showed that IPL therapy im-proved facial rhytids and skin quality withminimal adverse effects. In a 93-patient study, Sa-dick and colleagues57 showed that up to five IPLtreatments resulted in significant improvement ina variety of clinical indications of photoaging. Anewer technology that combins IPL with bipolarradiofrequency (electro-optical synergy or el�os)was evaluated by Sadick and colleagues58 The in-vestigators found it to be at least as efficacious forpigmentation and vascularity but potentially moreadvantageous for pore size, superficial rhytides,laxity, and texture. This difference was causedby the addition of the RF modality which can pen-etrate more deeply into the dermis to stimulatecollagen remodeling.

Potassium titanyl phosphateThe 532 nm wavelength of the potassium titanylphosphate (KTP) laser device is readily absorbedby oxyhemoglobin and melanin,59 making it espe-cially effective for treating red and brown discolor-ations due to photodamage60 and inducing growthof collagen and elastin fibers when endothelialdamage causes the release of cytokines. Combin-ing the KTP with the 1064 nm Nd:YAG laserdevice61 makes use of the greater penetrationdepth of the longer wavelength to create

a synergistic effect that further improves skin qual-ity and wrinkle reduction beyond what is achiev-able by KTP alone. The efficacy of the KTP laseris comparable to that of IPL.62 The smaller spotsize and ergonomic flexibility of the KTP hand-piece, however, promotes ease of use and allowspractitioners to focus on resistant lesions.Although fewer treatments are required, the riskof erythema and edema is higher with the KTP63

and the treatment is less tolerable.

COMMON SERVICESCellulite Reduction

Treatments of cellulite can be divided into fourmain categories: attenuation of aggravating fac-tors, physical and mechanical methods, pharma-cologic agents, and laser treatments (Table 6).

EndermologieEndermologie was developed in the 1970s asa way to soften scars and standardize physicaltherapy. Endermologie is a machine-assistedmassage system that applies negative pressureto the skin and subcutaneous tissues. Originallyfrom France, endermologie was found to havesome effects on smoothing the surface of theskin and reducing the body circumference.64 En-dermologie is still used today and it is now calledlipomassage. Once popular in plastic surgeons’and other cosmetic practitioners office, endermo-logie has lost favor because other methods ap-pear to be more effective, although some ofthese new technologies incorporate rollers andmassage.

IonithermieIonithermie is a treatment that was developed inFrance 25 years ago using galvanic and faradiccurrent causing passive contraction of the mus-cles and increasing circulation of the tissues. Theapplication of current is followed by an applicationof topical products, which vary between practi-tioners. Available in the US for only about twoyears, it appears to be available in many medicalspas. This treatment is touted to improve theappearance of cellulite and reduce ‘‘toxic waste’’in the tissues,65 although there are no peer-reviewed journal articles on this technique.

Bipolar radiofrequency, infrared light,vacuum and massageNumerous studies have shown the effectivenessof el�os technology to treat cellulite66–68 demon-strating an improvement of surface texture aswell as reduction of circumference of thighs orabdomen from 0.5–5.0 cm. The VelaSmooth(Syneron, Yokneam, Israel) combines bipolar

Table 6Cellulite, body shaping and tissue tightening devices


Accent XL Alma lasers Unipolar and bipolar radiofrequency

Titan Cutera Infrared light

TriActive Cynosure Laser plus vacuum massage

SmartLipo Deka/Cynosure Nd:YAG laser

C-Sculpt DermaMed international LED, cooling and massage

DermaWave no-needlemesotherapy system

DermaWave Dual wavelength (685 and 830 nm)diode laser plus three electricalwaveforms

Slim project General project Computerized vacuum assisted massage

Med sculpt General project Elastrometric microprocess mobilization,ultrasound, high-brilliance LED

TMT systemelectrotransport

Grupo body estheticlaboratories

Cutaneous electrotransport

LipoSonix system LipoSonix Ultrasound

Ultrapeel transdermionto system- needlesfree injection system

Mattioli Dermoelectroporation

LuxDeep IR fractionalinfrared handpiece

Palomar Infrared halogen

Regen Pollogen Monopolar plus bipolar radiofrequency

SkinTyte Sciton Broadband light

SmoothShapes SmoothShapes 650 and 900 nm Diode laser

SlimLine Spa Capsule Sybaritic Heat, oxygen and light

Dermasonic Sybaritic Ultrasound, suction, and massage

VelaSmooth Syneron Vacuum coupled bipolar radiofrequencyand infrared light

VelaShape Syneron Bipolar radiofrequency, infrared lightand mechanical massage

ThermaCool Thermage Monopolar radiofrequency

ThermaLipo ThermaMedic RF-AMFLI technology

Ulthera system Ulthera Ultrasound

CONTOUR I ver2 UltraShape Ultrasound


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radiofrequency, infrared light (700–2000 nm), andvacuum. Recently the VelaShape (Syneron, Yo-kneam, Isreal) was released, and it is consideredby some to be a second generation cellulite de-vice. This device increases the power of the bipo-lar radiofrequency from 20–50 W, amongst manyother modifications that make the coupling of theradiofrequency more effective. Two applicatorsare included, the VSmooth and the VContour,with the former for cellulite and the latter for con-touring. The claim is that the treatment time canbe reduced, the results improved, and the numberof treatments recommended changing from 14–16to 4–8. If the claims are true, this technique willchange the landscape of cellulite treatments,

making them more accessible and more popularfor this difficult to treat condition.

Laser plus vacuum massageThe TriActive laser (Cynosure, Westford, MA) is in-tended to reduce the appearance of cellulitethrough the combination of diode laser, contactcooling, suction, and massage. A split-thigh evalu-ation of TriActive versus VelaSmooth showed im-provement in cellulite noted with both deviceswithout a significant difference in efficacy.69

Other technologies in the market that purport tohelp with cellulite are: dual wavelength laserwith vacuum massage, SmoothShapes (ElemeMedical, Merrimack, NH); and dual wavelength


(685 nm and 830 nm) diode laser plus three electri-cal waveforms, DermaWave No-Needle Mesother-apy System (DermaWave) using a scientifictechnique.

Overall the devices for reductions of cellulitetake multiple treatments (8–16) and require fairlyfrequent maintenance (ie, monthly) to maintain aneffect. The results are modest, with some improve-ment in contour, reduction of rippling, and slightcircumferential reduction. This often is manifestin the patient’s perception of smoother skin andimprovement of the fit of clothing. If patients areproperly informed about the procedure, timing,and the need for maintenance as well as having re-alistic expectations, then these procedures can besuccessfully implemented into an esthetic practicewith success.

Tissue Tightening

Tissue tightening has been a major force in theaesthetic movement in the past five years. Initiatedby the technology of monopolar RF treatments,and later extended to unipolar and monopolar RFdevices, broadband infrared light, and bipolarRF with broadband light, the ability to firm and lifttissues of the face and body without surgery hasproved to be an important component of non-surgical aesthetic rejuvenation (see Table 6).

Monopolar radiofrequencyThermaCool (Thermage, Inc., Hayward, CA) wasthe first non-invasive technology developed spe-cifically to tighten dermal layers while leaving theepidermis undamaged. It delivers monopolar RFenergy deep into the dermis by use of a proprietary‘‘ThermaTip’’. The first tip available was the Ther-maTip TC, with a medium heating profile, whichpenetrated 2.4 mm. The addition of shallow profileThermaTip ST with penetration to 1.1 mm allowedfor treatment of thinner areas such as eyelids andhands. Modification to the cooling of the TC tipcreated the ThermaTip STC that still penetratesto 2.4 mm but is less cooling for a greater volumeof tissue heating. Most recently the ThermaTipDC was launched with a deep heating profile to4.3 mm for increased collagen tightening in thesubcutaneous layer of the skin. This is ideal fortreating areas of the body such as the abdomen,flanks, thighs, buttock, and arms.

The ThermaCool was FDA cleared in 2000 fordermatologic and general surgical procedures forelectrocoagulation and hemostasis. In 2002 itwas FDA approved for the ‘‘non-invasive treat-ment of periorbital wrinkles and rhytids,’’ expand-ing to clearance of ‘‘non-invasive treatment offacial wrinkles and rhytids’’ in 2004, and losingthe distinction of facial in 2005 with the clearance

of ‘‘non-invasive treatment of wrinkles and rhy-tids,’’ and specifically adding the non-invasivetreatment of periorbital wrinkles and rhytidsincluding the upper and lower eyelids’’ in 2007. Al-though Thermage does not yet have FDA approvalfor body shaping or deep contouring, it did receiveclearance for the ‘‘temporary improvement in ap-pearance of cellulite, relief of muscle spasm, reliefof minor muscle aches and pains, and temporaryimprovement of local circulation’’ in 2006.

Original treatment protocols suggested usinghigh fluence and performing few pulses. Treat-ments were often very painful and there was arelatively high rate of complications. Kist andcolleagues treated three subjects in the preauricu-lar region using a single pass or multiple passes(3–5) in the same 1.5 cm2 treatment area.70 Biop-sies taken from each region immediately posttreatment, 24 hours post treatment, and sixmonths post treatment showed an increasedamount of collagen fibril changes with increasingpasses. Changes seen in the samples that hadfive passes were similar to those in the singlepass higher energy treatments. Another study byWeiss and colleagues71 evaluated the safety of600 consecutive treatments of the face and neckover a four-year period. Treatment protocolsevolved from 1–3 passes over the entire area toone pass over the entire area and 2–4 vectorpasses to two passes over the entire area withup to four additional vector passes. Energy wasadjusted during treatment, based on patient painfeedback on a 0–4 scale with 0 being no pain orheat and 4 being intolerable pain or heat, somost pulses were rated at 2 by the patient. Theoverall rate of temporary unexpected adverseeffects as noted by patients or staff was 2.7%.Of particular note was that no patients reportedside effects beyond the expected temporary ery-thema and edema over the final year. Based onthese findings, now it is widely practiced to usemultiple passes with vector technique with alltissue tightening treatments and devices. Withthis treatment protocol, treatments have beenmuch less painful, the rate of complications hasgreatly diminished, and good results have becomemore prevalent and consistent.

Unipolar and bipolar radiofrequencyAccent Dual Mode RF System (Alma Lasers, Cae-sarea, Israel) consists of both unipolar and bipolarmode RF energies. The bipolar RF penetrates theskin more superficially, facilitating the treatmentof areas where skin is thinner and more delicate,such as the face. Tissue resistance to the bipolarRF current creates local, superficial dermal heat-ing that penetrates 2–6 mm. This device also

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uses a UniPolar mode, an innovation of AlmaLasers’, which delivers radiofrequency energydeep into the dermal and subdermal layers toefficiently treat large volumes of tissue. UniPolarRF generates alternating electromagnetic fieldsthat cause rotation and friction in the dipole watermolecules of deeper tissue and penetrates up to20 mm. One study showed that two treatmentson the subcutaneous tissue of the buttocks andthighs provide a volumetric contraction effect inthe majority of patients.72

Bipolar radiofrequency and infrared lightReFirme ST (Syneron, Yokneam, Israel) uses el�ostechnology combining bipolar RF and 700–2000nm infrared light. The intersection of the broad-band infrared light and the RF current createsa controlled, focused thermal energy. This tech-nology has been used for both facial73 and bodytightening.74

Vacuum assisted bipolar radiofrequencyFunctional Aspiration Controlled ElectrothermalStimulation (FACES) found in the Aluma (Lumenis,Yokneam, Israel) uses RF technology accompa-nied by vacuum-assisted positioning and foldingof the skin for the treatment of wrinkles and forskin tightening. By folding the skin, the dermis isplaced in a more direct alignment with the elec-trodes than when the electrodes are pressedonto the skin surface. A topical conductivemedium and the specially designed tips enablethe creation of concentrated heat in the dermis,maximizing both efficacy and safety. Subjectsreceiving up to eight facial treatments noted a sig-nificant decrease in dermal elastosis,75 and 90%patient satisfaction.

Infrared lightTitan (Cutera, Brisbane, CA) uses broad spectruminfrared light 1100–1800 nm. This is highly ab-sorbed by water as the chromophore in the dermisat a depth of 1–3 mm. The result is volumetricdermal heating causing immediate collagencontraction and neocollagenesis (a well-knowndelayed response to a thermal wound in the der-mis), similar to the effects of other tissue tighteningdevices. One of the authors of a three-centerperspective article treated 42 patients twice at1 month intervals over 18 months.76 The mean im-provement score was 1.83 (scale 0 to 4, with 4 de-noting maximum improvement) with an averagefollow-up time of 3.7 months. More than 90% oftreated patients showed visible improvement.

UltrasoundThirty-five adult patients were treated with a newultrasound device called Ulthera System (Ulthera,

Mesa, AZ) for tissue tightening. The full face andneck were treated with a single pass witha 7.5 Mhz or 4.4 MHz transducer with a 4.5 mm fo-cal depth and energies of 0.4–1.2 J. At least 0.5 cmof brow elevation was achieved in 89% of evalu-able subjects.77

Mesotherapy

Mesotherapy has used as a general term indicat-ing intradermal injection of multiple chemical sub-stances, but most now use the term to denote theinjection of a lipolytic agent for the purpose ofcircumferential reduction and body shaping.78

The active ingredient appears to be deoxycholate,a detergent that saponifies fat and leads to fat’sreabsorption by the body. Most of the time thelipolytic agent is formulated as a phosphtidylcho-line/deoxycholate mixture in various proportions,although a recent publication did study variouschemicals and their lipolytic activity.79

The lipolytic agent is injected—during multiplesessions—into the target area for fat lipolysis.Although widely used, this technique is not stan-dardized; has almost no peer-reviewed publica-tions supporting it; and is not approved by theFDA,80 although one paper showed efficacy fortreatment of lipomas.81 One concern with regardto this method is the absorption of the active ma-terial into the systemic circulation. Multiple treat-ments are required that result in fat necrosis andsubsequent absorption.

Acne Therapy

Light, heat, and RF energy devices and modalities,as well as photodynamic therapy (PDT) haveemerged as useful co-therapies or, in some cases,replacements for systemic medications. There arestudies to show efficacy for blue, red and blue/redlight combinations, pulsed dye and KTP laser,photodynamic therapy with various light sources,intense pulsed light with suction, infrared laser,and radiofrequency devices (Table 7).

Therapy with visible light takes advantage of thephotosensitivity of porphyrins produced by Pro-pionibacterium acnes,82 the skin bacterium asso-ciated with acne. Activation of protoporphyrin IX(PpIX) in the presence of oxygen produces singletoxygen, a metastable intermediate that destroyscells (in this case, P. acnes).83,84 PpIX absorptionpeaks occur at 410 (maximum), 505, 540, 580,and 630 nm,85 all wavelengths in the visible lightspectrum.

When light is used alone, biweekly or weeklytreatments up to eight treatments are usuallyrequired for efficacy. Both LED sources and non-LED sources may be used; the advantages of

Table 7Acne therapy devices


LightPod neo XL Aerolase Nd:YAG

Harmony Alma lasers AFT pulsed light, Nd:YAG

Smoothbeam Candela Diode

Vbeam Candela Pulsed dye

CT3 Plus CoolTouch Nd:YAG


BLU-U DUSA Blue light

NaturaLight Focus medical Pulsed light

RevLite HOYA conbio EO Q-switched Nd:YAG with photoacoustictherapy pulse (PTP) technology

MedLite C6 HOYA conbio EO Q-switched Nd:YAG

VariLite Iridex KTP, Diode

Spectra VRM II Lutronic Q-switched Nd:YAG

Quantel medical aramis MedSurge advances Erbium glass laser

Clareon AR Novalis Pulsed light

Solarus AR Novalis Pulsed light

StarLux LuxG handpiece Palomar Pulsed light

Omnilux blue LED Blue light

Omnilux revive LED Red light

Eterna giovinezza Quanta Intense pulsed light

ARAMIS Quantel medical Erbium glass laser


SPR Radiancy LHE (light and heat energy)

SpaTouch pro Radiancy LHE (light and heat energy)

ClearTouch lite Radiancy LHE (light and heat energy)

ThermaScan Sciton Nd:YAG

BBL Sciton Pulsed light

Profile Sciton Er:YAG, Nd:YAG, Pulsed light



eLight AC Syneron Optical energy and RF



this therapy are painless treatments that are safefor any skin type. Disadvantages include theneed for multiple treatments that can take up to20 minutes each and the need for relatively fre-quent maintenance.

Photodynamic therapyPDT usually uses either blue or red light, intensepulsed light, or pulsed dye laser to activate5-aminolevulinic acid (Levulan Kerastick, DusaPharmaceuticals, Wilmington, MA), a precursorof PpIX. Since there is a preferential uptake ofthis drug by sebaceous glands, there resultsa high concentration of PpIX in the gland. This

creates an opportunity to not only kill the bacteriabut also to destroy or reduce the gland capacity,leading to the potential for more long-term im-provement. Usually done as a series of 3–4 treat-ments over 6–12 weeks, there can be downtimewith this procedure, due to the fact that there isa 48-hour of window of photosensitivity. However,PDT is capable of treating very severe and evencystic acne effectively. Experts in this area recom-mend using IPL or pulsed dye to activate the drugand using a short contact (10–30 minutes)86 to limitthe non-specific absorption of 5-ala in the epider-mis. Alexiades-Armenakas showed that ALA-PDTwith long-pulsed, pulsed dye laser activation was

Taub354

effective against a variety of acne lesion types withminimal adverse effects.87 Gold and colleagues88

were the first to use IPL for ALA-PDT for acneand demonstrated its effectiveness. The resultsof these and other studies culminated in a consen-sus recommendation for the treatment of acne:89

Consensus panel members agreed that ALA PDTprovides: (1) the best results when used to treatinflammatory and cystic acne, and (2) modestclearance when used to treat comedonal acne.

Pulsed dye laserThe efficacy and safety of the pulsed dye laser(PDL) has been studied by Seaton and col-leagues90 and by Orringer and colleagues.91 Onestudy showed a clear improvement and the otherfound no improvement. The reasons for the dis-crepancy between the results are not clear, andno further studies have been undertaken.

Potassium titanyl phosphate laserThe 532 nm potassium titanyl phosphate (KTP)laser has been evaluated for the treatment ofmild to moderate acne.92 The randomized split-face study of 26 patients showed moderate reduc-tion in acne score at 1 week and diminishedreduction at 4 weeks post-treatment, supportedby histologic studies. The study suggests thatthe KTP laser may have promise in the treatmentof acne.

1450-nm laserIn 2002, Paithankar and colleagues93 showed thata mid-infrared (1450-nm) laser device (Smooth-beam, Candela, Wayland, MA) with cryogen spraycooling could thermally damage the upper dermis(where sebaceous glands are located) withoutinjuring the epidermis in an animal model. In theirclinical study of 27 subjects with acne on the bilat-eral areas of the upper back, the authors showedthat lesion counts on the treated sides of the backswere statistically significantly reduced after treat-ments compared with the control sides; theyshowed that side effects were minimal and tran-sient. Other studies showing clinical efficacyhave been published.94

Jih and colleagues95 completed a 20-patientstudy of the 1450 nm wavelength and treatingpatients with skin types II–VI with inflammatoryacne. Three split-face treatments were performedat 3- to 4-week intervals at randomly assignedfluences of 14 J/cm2 or 16 J/cm2. Mean lesioncount reductions were 75.1% for 14 J/cm2 and70.6% for 16 J/cm2. These improvements weremaintained at a 12-month follow-up. The treat-ments were tolerated with a minimal side effectsand an average visual analog pain score of four

to six. One criticism of 1450 nm laser therapy isthat it is too painful for many teenagers to tolerate.

From the available data, the 1450 nm infraredlaser appears to be an important modality for thetreatment of acne. The results with the KTP laserare limited and preliminary. However, it is unlikelythat any short wavelength that did not havea profound effect on the sebaceous gland couldproduce a long-term acne remission by itself.

RadiofrequencyIn the first report on the use of RF energy (Therma-cool) for the treatment of moderate to severeacne,96 most patients received a single treatmentand were followed for up to 8 months. Effectsdue to RF alone are not clear, however, because9 of the 22 patients received medical therapiesfor acne during the RF treatment period. Theauthors obtained encouraging results, however,and suggested that the responses are due to inhi-bition of sebaceous gland activity by RF-producedheat.

Prieto and colleagues97,98 evaluated the efficacyand safety of the Aurora AC (Syneron Medical Ltd.,Yokneam, Israel), a device that delivers pulsedblue light and RF energies by el�os. An eight-treatment course (twice weekly for four weeks)resulted in reductions in: (1) lesion count; (2) per-centage of follicles with perifolliculitis; and (3)areas of sebaceous glands.

The results of both studies suggest that RF isa promising nonablative alternative for the treat-ment of acne, but too little information is availableto be able to comment on effective protocols,duration of effect, or reproducibility of results.

Suction with pulsed lightA new device using pneumatic therapy (Ppx), (Iso-laz Device, Aesthera, Pleasanton, CA) has beenavailable for a short period of time; the devicecombines vacuum suction and pulsed light. Thesuction brings the skin closer to the light, makingthe penetration of all visible wavelengths deeper.The device also functions as a ‘‘pore-cleansing’’device. Early accounts of improvements with thisdevice are encouraging, although there are nopublished papers in peer-reviewed journals.Although treatment protocols have not been deter-mined, most practitioners using this device do fourtreatments over eight weeks, with varying degreesof subsequent maintenance.

LESS COMMONMEDICAL SERVICES

Many other medical services may be performed ina medical spa (see Table 1). These are proceduresusually performed by a physician. A completereview of these is beyond the scope of this article.


LESS COMMON SPA SERVICES

Many other spa services, those traditionally asso-ciated with a non-medical spa, may be performedin a medical spa (see Table 1).

SUMMARY

The variety of spa equipment reflects the predilec-tion and experience of the medical director and/orowner. Core services such as microdermabrasion,medical facials, photofacials, laser hair removal,and injectables are fixtures at most medispas.Procedures such as cellulite reduction, tissuetightening, and procedural treatments for acneare also fairly common. More invasive proceduressuch as resurfacing, sclerotherapy, photodynamictherapy, laser assisted lipoplasty, and tattooremoval are more common in medical spas wherethe medical director is often the owner and directlyinvolved onsite. Multisite medispas often rely onmultiplatform devices to ensure uniformity ofservices and ease of training, as well as relyingon allied health care providers.

REFERENCES

1. Tsai RY, Wang CN, Chan HL. Aluminum oxide crystal

microdermabrasion. A new technique for treating

facial scarring. Dermatol Surg 1995;21(6):539–42.

2. Shim EK, Barnette D, Hughes K, et al. Microdermab-

rasion: a clinical and histopathologic study. Derma-

tol Surg 2001;27(6):524–30.

3. Rajan P, Grimes PE. Skin barrier changes induced

by aluminum oxide and sodium chloride microder-

mabrasion. Dermatol Surg 2002;28(5):390–3.

4. Freedman BM, Rueda-Pedraza E, Waddell SP. The

epidermal and dermal changes associated with

microdermabrasion. Dermatol Surg 2001;27(12):

1031–3 [discussion: 1033–4].

5. Katz BE, Truong S, Maiwald DC, et al. Efficacy of

microdermabrasion preceding ALA application in

reducing the incubation time of ALA in laser PDT.

J Drugs Dermatol 2007;6(2):140–2.

6. Lee WR, Shen SC, Kuo-Hsien W, et al. Lasers and

microdermabrasion enhance and control topical

delivery of vitamin C. J Invest Dermatol 2003;

121(5):1118–25.

7. About.com. Skin and beauty. Available at: http://

dermatology.about.com/od/cosmeticprocedure/a/

microdermhx.htm. Accessed November 21, 2007.

8. Cosmetic Surgery Quick Facts: 2005 ASAPS Statis-

tics. Available at: http://www.surgery.org/press/

procedurefacts-asqf.php. Accessed November 21,

2007.

9. Effron C, Briden ME, Green BA. Enhancing cosmetic

outcomes by combining superficial glycolic acid

(alpha-hydroxy acid) peels with nonablative lasers,

intense pulsed light, and trichloroacetic acid peels.

Cutis 2007;79(1 Suppl Combining):4–8.

10. Grimes PE. The safety and efficacy of salicylic acid

chemical peels in darker racial-ethnic groups.

Dermatol Surg 1999;25(1):18–22.

11. Zakopoulou N, Kontochristopoulos G. Superficial

chemical peels. J Cosmet Dermatol 2006;5(3):

246–53.

12. Sharquie KE, Al-Tikreety MM, Al-Mashhadani SA.

Lactic acid chemical peels as a new therapeutic

modality in melasma in comparison to Jessner’s

solution chemical peels. Dermatol Surg 2006;

32(12):1429–36.

13. Sarkar R, Kaur C, Bhalla M, et al. The combination of

glycolic acid peels with a topical regimen in the

treatment of melasma in dark-skinned patients:

a comparative study. Dermatol Surg 2002;28(9):

828–32 [discussion: 832].

14. Kim SW, Moon SE, Kim JA, et al. Glycolic acid

versus Jessner’s solution: which is better for facial

acne patients? A randomized prospective clinical

trial of split-face model therapy. Dermatol Surg

1999;25(4):270–3.

15. Khunger N, Sarkar R, Jain RK. Tretinoin peels versus

glycolic acid peels in the treatment of Melasma in

dark-skinned patients. Dermatol Surg 2004;30(5):


16. Kligman D, Kligman AM. Salicylic acid peels for the

treatment of photoaging. Dermatol Surg 1998;24(3):

325–8.

17. Murad H, Shamban AT, Premo PS. The use of

glycolic acid as a peeling agent. Dermatol Clin

1995;13(2):285–307.

18. Lee HS, Kim IH. Salicylic acid peels for the treatment

of acne vulgaris in Asian patients. Dermatol Surg

2003;29(12):1196–9 [discussion: 1199].

19. Atzori L, Brundu MA, Orru A, et al. Glycolic acid

peeling in the treatment of acne. J Eur Acad Derma-

tol Venereol 1999;12(2):119–22.

20. About.com. Spas. Available at: http://spasabout.

com/od/massage/a/whatisafacial.htm. Accessed

November 21, 2007.

21. Beauty School Directory. State license requirements.

Available at: http://www.beautyschoolsdirectory.com/

faq/state_req.php. Accessed November 21, 2007.

22. Shorr N, Seiff SR, Kopelman J. The use of botulinum

toxin in blepharospasm. Am J Ophthalmol 1985;

99(5):542–6.

23. Scott AB, Kennedy R, Stubbs HA. Botulinum a toxin

injection as a treatment for blepharospasm. Arch

Ophthalmol 1985;103(3):347–50.

24. Tsoy EA, Buckley EG, Dutton JJ. Treatment of bleph-

arospasm with botulinum toxin. Am J Ophthalmol

1985;99(2):176–9.

25. Magoon EH. Botulinum chemodenervation for

strabismus and other disorders. Int Ophthalmol

Clin 1985;25(4):149–59.

http://dermatology.about.com/od/cosmeticprocedure/a/microdermhx.htm



http://www.surgery.org/press/procedurefacts-asqf.php



http://spas.about.com/od/massage/a/whatisafacial.htm



http://www.beautyschoolsdirectory.com/faq/state_req.php

http://www.beautyschoolsdirectory.com/faq/state_req.php

Taub356

26. Helveston EM. Botulinum injections for strabismus.

J Pediatr Ophthalmol Strabismus 1984;21(5):202–4.

27. Carruthers JD, Carruthers JA. Treatment of glabellar

frown lines with C. botulinum-A exotoxin. J Dermatol

Surg Oncol 1992;18(1):17–21.

28. American Society for Aesthetic Plastic Surgery.

Available at: http://www.surgery.org/download/

2006-Top5.pdf. Accessed November 21, 2007.

29. Carruthers A, Carruthers J. Clinical indications and

injection technique for the cosmetic use of botulinum

A exotoxin. Dermatol Surg 1998;24(11):1189–94.

30. Available at: http://www.fda.gov/fdac/departs/2002/

502_upd.html. Accessed November 21, 2007.

31. Alam M, Yoo SS. Technique for calcium hydroxylap-

atite injection for correction of nasolabial fold de-

pressions. J Am Acad Dermatol 2007;56(2):285–9.

32. Vleggar D. Soft-tissue augmentation and the role of

poly-L-lactic acid. Plast Reconstr Surg 2006;118

(3 Suppl):46S–54S.

33. Carruthers JD, Carruthers A. Facial sculpting and tis-

sue augmentation. Dermatol Surg 2005;31(11 Pt 2):

1604–12.

34. Safety and effectiveness of EpiLaser. Available at:

http://www.fda.gov/cdrh/pdf/K980517.pdf. Accessed

November 21, 2007.

35. Dierickx C, Alora MB, Dover JS. A clinical overview

of hair removal using lasers and light sources. Der-

matol Clin 1999;17(2):357–66, ix.

36. Grossman M, Dierickx C, Farinelli W, et al. Damage

to hair follicles by normal-mode ruby laser. J Am

Acad Dermatol 1996;35(6):889–94.

37. Dierickx CC, Grossman MC, Farinelli WA, et al. Per-

manent hair removal by normal-mode ruby laser.

Arch Dermatol 1998;134(7):837–42.

38. Garcia C, Alamoudi H, Nakib M, et al. Alexandrite

laser hair removal is safe for Fitzpatrick skin types

IV–VI. Dermatol Surg 2000;26(2):130–4.

39. McDaniel DH, Lord J, Ash K, et al. Laser hair

removal: a review and report on the use of the

long-pulsed alexandrite laser for hair reduction of

the upper lip, leg, back, and bikini region. Dermatol

Surg 1999;25(6):425–30.

40. Eremia S, Li C, Newman N. Laser hair removal with

alexandrite versus diode laser using four treatment

sessions: 1-year results. Dermatol Surg 2001;

27(11):925–9 [discussion: 929–30].

41. Bouzari N, Nouri K, Tabatabai H, et al. The role of

number of treatments in laser-assisted hair removal

using a 755-nm alexandrite laser. J Drugs Dermatol

2005;4(5):573–8.

42. Lou WW, Quintana AT, Geronemus RG, et al. Pro-

spective study of hair reduction by diode laser

(800 nm) with long-term follow-up. Dermatol Surg

2000;26(5):428–32.

43. Campos VB, Dierickx CC, Farinelli WA, et al. Hair

removal with an 800-nm pulsed diode laser. J Am

Acad Dermatol 2000;43(3):442–7.

44. Tanzi EL, Alster TS. Long-pulsed 1064-nm Nd:YAG

laser-assisted hair removal in all skin types. Derma-

tol Surg 2004;30(1):13–7.

45. Bedewi AF. Hair removal with intense pulsed light.

Lasers Med Sci 2004;19(1):48–51.

46. Goldberg DJ, Marmur ES, Hussain M. Treatment

of terminal and vellus non-pigmented hairs with

an optical/bipolar radiofrequency energy source-

with and without pre-treatment using topical ami-

nolevulinic acid. J Cosmet Laser Ther 2005;7(1):

25–8.

47. Sadick NS, Laughlin SA. Effective epilation of white

and blond hair using combined radiofrequency

and optical energy. J Cosmet Laser Ther 2004;

6(1):27–31.

48. Mandt N, Troilus A, Drosner M. Epilation today:

physiology of the hair follicle and clinical photo-

epilation. J Investig Dermatol Symp Proc 2005;

10(3):271–4.

49. Kauvar A, Rosen N, Khrom T. A newly modified

595-nm pulsed dye laser with compression hand-

piece for the treatment of photodamaged skin.

Lasers Surg Med 2006;38(9):808–13.

50. Zelickson B, Kilmer SL, Bernstein E, et al. Pulsed

dye laser therapy for sun damaged skin. Lasers

Surg Med 1999;25:229–36.

51. Bjerring P, Clement M, Heickendorff L, et al. Selec-

tive non-ablative wrinkle reduction by laser. J Cutan

Laser Ther 2000;2:9–15.

52. Tanghetti E, Sherr E, Alvarado S. Multipass treat-

ment of photodamage using the pulse dye laser.


53. Hsu T, Zelickson B, Dover J, et al. Multicenter study

of the safety and efficacy of a 585 nm pulsed-dye

laser for the nonablative treatment of facial rhytides.


54. Goldberg D. New collagen formation after dermal

remodeling with an intense pulsed light source.

J Cutan Laser Ther 2000;2:59–61.

55. Bitter P. Noninvasive rejuvenation of photodamaged

skin using serial, full-face intense pulsed light

treatments. Dermatol Surg 2000;26:835–42.

56. Goldberg D, Cutler K. Nonablative treatment of

rhytids with intense pulsed light. Lasers Surg Med

2000;26:196–200.

57. Sadick N, Weiss R, Kilmer S, et al. Photorejuvenation

with intense pulsed light: results of a multi-center

study. J Drugs Dermatol 2004;3:41–9.

58. Sadick NS, Alexiades-Armenakas M, Bitter P Jr,

et al. Enhanced full-face skin rejuvenation using

synchronous intense pulsed optical and conducted

bipolar radiofrequency energy (ELOS): introducing

selective radiophotothermolysis. J Drugs Dermatol

2005;4(2):181–6.

59. Carniol P, Farley S, Friedman A. Long-pulse 532-nm

diode laser for nonablative facial skin rejuvenation.

Arch Facial Plast Surg 2003;5:511–3.

http://www.surgery.org/download/2006-Top5.pdf

http://www.surgery.org/download/2006-Top5.pdf

http://www.fda.gov/fdac/departs/2002/502_upd.html

http://www.fda.gov/fdac/departs/2002/502_upd.html

http://www.fda.gov/cdrh/pdf/K980517.pdf

http://www.fda.gov/cdrh/pdf/K980517.pdf


60. Tan M, Dover J, Hsu T, et al. Clinical evaluation of

enhanced nonablative skin rejuvenation using

a combination of a 532 and a 1,064 nm laser. Lasers

Surg Med 2004;34:439–45.

61. Lee M. Combination 532-nm and 1064-nm lasers for

noninvasive skin rejuvenation and toning. Arch

Dermatol 2003;139:1265–76. Erratum in: Arch Der-

matol 2004;140:625.

62. Butler E, McClellan S, Ross E. Split treatment of

photodamaged skin with KTP 532 nm laser with

10 mm handpiece versus IPL: a cheek-to-cheek

comparison. Lasers Surg Med 2006;38:124–8.

63. Weiss R, Weiss M, Beasley K, et al. Our approach to

non-ablative treatment of photoaging. Lasers Surg

Med 2005;37:2–8.

64. Chang P, Wiseman J, Jacoby T, et al. Noninvasive

mechanical body contouring: (Endermologie)

a one-year clinical outcome study update. Aesthetic

Plast Surg 1998;22(2):145–53.

65. Available at: http://www.sonachicago.com/Ionithermie.

htm?gclid5CLegqsClso8CFQRuZQodBWBuMQ. Ac-

cessed November 21, 2007.

66. Wanitphakdeedecha R, Manuskiatti W. Treatment of

cellulite with bipolar radiofrequency, infrared heat,

and pulsatile suction device: a pilot study. J Cosmet

Dermatol 2006;5(4):284–8.

67. Sadick N, Margo C. A study evaluating the safety

and efficacy of the velasmooth system in the treat-

ment of cellulite. J Cosmet Laser Ther 2007;9(1):

15–20.

68. Boey G. Cellulite treatment with a radiofrequency,

infrared light, and tissue manipulation combination

device [abstract]. American Society Of Dermato-

logic Surgery Annual Meeting. Desert Springs

(CA), October 29, 2006.

69. Nootheti PK, Magpantay A, Yosowitz G, et al. A sin-

gle center, randomized, comparative, prospective

clinical study to determine the efficacy of the Vela-

Smooth system versus the Triactive system for the

treatment of cellulite. Lasers Surg Med 2006;

38(10):908–12.

70. Kist D, Burns J, Sanner R, et al. Ultrastructural eval-

uation of multiple pass low energy versus single

pass high energy radio-frequency treatment. Lasers

Surg Med 2006;38(2):150–4.

71. Weiss RA, Weiss MA, Munavalli G, et al. Monopolar

radiofrequency facial tightening: a retrospective

analysis of efficacy and safety in over 600 treat-

ments. J Drugs Dermatol 2006;5(8):707–12.

72. Emilia del Pino M, Rosado RH, Azuela A, et al. Effect

of controlled volumetric tissue heating with radiofre-

quency on cellulite and the subcutaneous tissue of

the buttocks and thighs. J Drugs Dermatol 2006;

5(8):714–22.

73. Sadick N. Bipolar radiofrequency for facial rejuvena-

tion. Facial Plast Surg Clin North Am 2007;15(2):

161–7, v.

74. Sleightholm R, Bartholomeusz H. Skin tightening

and treatment of facial rhytides with combined infra-

red light and bipolar radiofrequency technology.

White paper. Syneron Medical Ltd., Yokneam, Israel.

75. Gold MH, Goldman MP Jr, Rao J. Treatment of wrin-

kles and elastosis using vacuum-assisted bipolar ra-

diofrequency heating of the dermis. Dermatol Surg

2007;33(3):300–9.

76. Taub AF, Battle EF Jr, Nikolaidis G. Multicenter

clinical perspectives on a broadband infrared light

device for skin tightening. J Drugs Dermatol 2006;

5(8):771–8.

77. Alam M, White L, Agha R, et al. Safety and Efficacy

of a new ultrasound device for skin tightening of

the face and neck. Presented at the 2007 meeting

of the American Society for Dermatologic Surgery.

Chicago, October 14, 2007.

78. Rotunda AM, Kolodney MS. Mesotherapy and phos-

phatidylcholine injections: historical clarification and

review. Dermatol Surg 2006;32(4):465–80.

79. Caruso MK, Roberts AT, Bissoon L, et al. An evalua-

tion of mesotherapy solutions for inducting lipolysis

and treating cellulite. J Plast Reconstr Aesthet

Surg 2007; [epub ahead of print].

80. Rotunda AM, Avram NM, Avram AS. Cellulite: is

there a role for injectables? J Cosmet Laser Ther

2005;7(3–4):147–54.

81. Rotunda AM, Ablon G, Kolodney MS. Lipomas treated

with subcutaneous deoxycholate injections. J Am

Acad Dermatol 2005;53(6):973–8. Epub 2005 Oct 19.

82. Lee W, Shalita A, Poh-Fitzpatrick M. Comparative

studies of porphyrin production in Propionibacte-

rium acnes and Propionibacterium granulosum.

J Bacteriol 1978;133:811–5.

83. Weishaupt K, Gomer C, Dougherty T. Identification

of singlet oxygen as the cytotoxic agent in photoi-

nactivation of a murine tumor. Cancer Res 1976;36:

2326–9.

84. Niedre M, Yu C, Patterson M, et al. Singlet oxygen

luminescence as an in vivo photodynamic therapy

dose metric: validation in normal mouse skin with

topical amino-levulinic acid. Br J Cancer 2005;92:

298–304.

85. Taub AF. Photodynamic therapy in dermatology:

history and horizons. J Drugs Dermatol 2004;

3(Suppl 1):S8–25.

86. Taub AF. A comparison of intense pulsed light,

combination radiofrequency and intense pulsed

light, and blue light in photodynamic therapy for

acne vulgaris. J Drugs Dermatol 2007;6(10):1010–6.

87. Alexiades-Armenakas M. Long-pulsed dye laser-

mediated photodynamic therapy combined with

topical therapy for mild to severe comedonal, inflam-

matory, or cystic acne. J Drugs Dermatol 2006;5:

45–55.

88. Gold M, Bradshaw V, Boring M, et al. The use of

a novel intense pulsed light and heat source and

http://www.sonachicago.com/Ionithermie.htm?gclid=CLegqsClso8CFQRuZQodBWBuMQ



Taub358

ALA-PDT in the treatment of moderate to severe

inflammatory acne vulgaris. J Drugs Dermatol

2004;3(6 Suppl):S15–9.

89. Nestor M, Gold M, Kauvar A, et al. The use of

photodynamic therapy in dermatology: results of a

consensus conference. J Drugs Dermatol 2006;5:

140–54.

90. Seaton E, Charakida A, Mouser P, et al. Pulsed-dye

laser treatment for inflammatory acne vulgaris: rand-

omised controlled trial. Lancet 2003;362:1347–52.

91. Orringer J, Kang S, Hamilton T, et al. Treatment of

acne vulgaris with a pulsed dye laser: a randomized

controlled trial. JAMA 2004;291:2834–9.

92. Baugh W, Kucaba W. Nonablative phototherapy for

acne vulgaris using the KTP 532 nm laser. Dermatol

Surg 2005;31:1290–6.

93. Paithankar D, Ross E, Saleh B, et al. Acne treatment

with a 1,450 nm wavelength laser and cryogen

spray cooling. Lasers Surg Med 2002;31:106–14.

94. Wang S, Counters J, Flor M, et al. Treatment of

inflammatory facial acne with the 1,450 nm diode

laser alone versus microdermabrasion plus the

1,450 nm laser: a randomized, split-face trial. Der-

matol Surg 2006;32:249–55 [discussion: 255].

95. Jih MH, Friedman PM, Goldberg LH, et al. The

1450-nm diode laser for facial inflammatory acne

vulgaris: dose-response and 12-month follow-up

study. J Am Acad Dermatol 2006;55:80–7.

96. Ruiz-Esparza J, Gomez J. Nonablative radiofre-

quency for active acne vulgaris: the use of

deep dermal heat in the treatment of moderate

to severe active acne vulgaris (thermotherapy):

a report of 22 patients. Dermatol Surg 2003;29:

333–9.

97. Rotunda A, Bhupathy A, Rohrer T. The new age

of acne therapy: light, lasers, and radiofrequency.

J Cosmet Laser Ther 2004;6:191–200.

98. Prieto V, Zhang P, Sadick N. Evaluation of pulsed

light and radiofrequency combined for the treat-

ment of acne vulgaris with histologic analysis of

facial skin biopsies. J Cosmet Laser Ther 2005;7:

63–8.

Understanding andTreating Various SkinTypes : The Baumann SkinType Indicator
Leslie Baumann, MD
KEYWORDS� Antioxidants � Aquaporin-3 � Natural mosturizing factor� Protease-activated receptor-2 � Telomeres� Tyrosinase � Inhibitors � Xerosis

In the early 1900s, cosmetics entrepreneur HelenaRubinstein claimed that dry, oily, combination, orsensitive were the best words to label what couldbe considered the four fundamental types ofskin. For the ensuing century, these categorieshave been used to characterize skin types withonly minor, if any, modifications. During the sametime period, the skin care product market has de-veloped into a multibillion dollar industry featuringnumerous innovations and frequent new productintroductions. The industry has, in recent years,also witnessed the emergence of ‘‘cosmeceuti-cals,’’ a new product category that refers to cos-metic products that may impart some biologicfunction to the skin.

Amidst a market now deluged with a plethora ofskin care products, the traditional designations forskin types have been seen as incomplete or inad-equate descriptions of skin, thus providing insuffi-cient guidance for practitioners and consumers toselect the most suitable products. A more thor-ough depiction of skin type could yield such assis-tance to patients/consumers and physicians,particularly because some products are nowmarketed based on the skin types for which theyare designed. But does a person have simply dryor sensitive skin? The skin types identified byRubinstein tell only a fraction of the story. Aninnovative approach to classifying skin type, theBaumann Skin Type Indicator (BSTI), treats twoof Rubinstein’s categories as one of four

University of Miami Cosmetic Center, 4701 North MeridiE-mail address: [email protected]


dichotomous parameters to characterize facialskin types: dry or oily; sensitive or resistant; pig-mented or nonpigmented; and wrinkled or un-wrinkled (tight). Evaluating skin based on all fourparameters yields 16 potential skin-type permuta-tions. The BSTI is a 64-item questionnaire that isdesigned to determine baseline skin type identifi-cations and assessments after significant lifechanges.1

All four parameters must be considered forpatients to accurately self-assess their skin typeor for practitioners to be able to make appropriateskin care recommendations to their patients.For example, a person who has dry, sensitive,pigmented, wrinkled skin would require markedlydifferent skin care products or treatments thanan individual who has oily, resistant, nonpig-mented, unwrinkled skin.

This article describes the four parameters thatmake up the BSTI, focusing on basic scienceand defining characteristics and summarizing the16 skin-type variations (Table 1). Variability isa key concept underlying the questionnaire andaccurately identifying skin type. Skin types arenot necessarily static. Moving to a different climateor experiencing marked stress fluctuations, preg-nancy, menopause, or other significant exogenousand endogenous events can engender skin typechanges. Significantly, noninvasive, primarily topi-cal therapies are the focus of treatments based onthe BSTI system.

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Baumann360

SKIN HYDRATIONOily Versus Dry

Having skin that is sufficiently hydrated, whichwould fall in the middle of the oily–dry spectrum,is most often ideal regarding this parameter. Thedry end of this dichotomy is considered more trou-blesome than the oily end, however. Dry skin, alsoknown as xerosis, is the result of a convoluted,multifactorial cause, but its description is relativelystraightforward. Dry skin is characterized by dullcolor (typically gray white), rough texture, and anelevated number of ridges.2 Levels of stratumcorneum lipids, sebum, natural moisturizing factor,and aquaporin are considered to be the mostimportant factors that regulate the degree of, orcontribute to, dry skin.

Of these factors, the role of the stratum corneum(SC), especially its capacity to maintain skin hydra-tion, is the most significant factor in the mechanismof xerosis. In turn, the SC is composed of ceram-ides, fatty acids, and cholesterol, among otherless active constituents. When present in theproper amount and balance, these three groupsof primary constituents of the SC contribute to pro-tecting the skin and keeping it watertight. SC equi-librium is also believed to be maintained throughstimulation of keratinocyte lipid synthesis andkeratinocyte proliferation by primary cytokines.3

Improper balance in these constituents contrib-utes to a cascade of interrelated events, includinga diminished capacity to maintain water andincreased vulnerability to external factors, whichincreases sensitivity of the SC. Xerosis resultsthrough such impairment in the SC. These flawsin the skin barrier lead to increases in transepi-dermal water loss (TEWL). The enzymes necessaryfor desmosome metabolism are inhibited byinsufficient hydration, resulting in the abnormaldesquamation of corneocytes.4 Superficial SCdesmoglein I levels simultaneously remain high.The resultant compromised desquamation yieldsa visible collection of keratinocytes manifesting inskin that is rough and dry in appearance.5 A pertur-bation in the lipid bilayer of the SC because of in-creased fatty acid levels and decreased ceramidelevels is also associated with dry skin.6 The lipidbilayer is also susceptible to being influenced orinhibited by exogenous factors, such as ultravioletradiation, detergents, acetone, chlorine, and pro-longed water exposure or immersion. Recentresearch has indicated that local changes in pHmay explain the initial cohesion and ultimatedesquamation of corneocytes from the surface ofthe SC. It is believed that these changes selec-tively activate several extracellular proteases ina pH-dependent fashion.7

The Baumann Skin Type Indicator 361

Natural moisturizing factor (NMF), an intracellu-lar, hygroscopic compound found only in the SCthat is released by lamellar bodies and synthesizedby way of the breakdown of the protein filaggrin,plays an important role in maintaining water withinskin cells. Filaggrin, which consists of lactic acid,urea, citrate, and sugars, is broken down by a cyto-solic protease into free amino acids, such as argi-nine, glutamine (glutamic acid), and histidine, inthe stratum compactum, an outer layer of theSC.8 These water-soluble compounds stay in thekeratinocytes and bind strongly to water mole-cules. The pace of filaggrin decomposition andthe level of NMF present are attributed to aspar-tate protease (cathepsin).9 Changes in external hu-midity can influence cathepsin, potentially yieldingfluctuations in NMF production. NMF productiontypically increases over the course of severaldays after an individual enters a low-humidity envi-ronment.10 Low levels of NMF are associated withxerosis and ichthyosis vulgaris. NMF developmentcan be inhibited by ultraviolet radiation and surfac-tants. There are no products or procedures yetavailable to artificially regulate NMF production.

Aquaporin-3 (AQP3) is an important member inthe family of homologous integral membraneproteins that selectively facilitate the transport ofwater and small neutral solutes, such as glyceroland urea, across biologic membranes.11 AQP3 ispresent in the kidney collecting ducts and epider-mis, and in the urinary, respiratory, and digestivetracts. This water channel protein that ultimatelyinfluences skin hydration is a member of a subclassof aquaporins known as aquaglyceroporins, whichtransport water, glycerol, urea, and other smallsolutes. In 2002 AQP3 was demonstrated to beexpressed abundantly in the plasma membraneof human epidermal keratinocytes.12 It is believedthat the water conduction function in the skin oc-curs along an osmotic gradient beneath the SC,where high AQP3-mediated water permeability isdisplayed. AQP3 water clamps viable epidermallayers to facilitate the hydration of skin layersbelow the SC.

A high concentration of solutes (Na1, K1, andCl�) and a low concentration of water (13%–35%)13 are present in the superficial SC andproduce the steady-state gradients of solutesand water from the skin surface to the viable epi-dermal keratinocytes.14–16 Although transepithelialfluid transport has been studied extensively in kid-neys and lungs, the molecular mechanisms of fluidtransport across epidermal keratinocyte layershave not been clearly elucidated. Likewise, therelationship between keratinocyte fluid transportand SC hydration is not well understood. It isbelieved, however, that AQP3 improves

transepidermal water permeability to shield theSC from water evaporating from the skin surfaceor to disperse water gradients throughout the epi-dermal keratinocyte layer.12 In a study assessingthe functional expression of AQP3 in human skin,investigators found that, consistent with AQP3 in-volvement, the water permeability of human epi-dermal keratinocytes was hindered by mercurialsand low pH.12 In a different study, some of thesame researchers investigated skin phenotype intransgenic mice lacking AQP3 and found signifi-cantly lower water and glycerol permeability inthe AQP3 null mice, buttressing previous evidencethat AQP3 acts as a plasma membrane water/glycerol transporter in the epidermis.17 Conduc-tance measurements showed substantially lowerSC water content in most cutaneous areas of thenull mice. Epidermal cell water permeability is nota significant determinant of SC hydration, how-ever, because water transport across AQP3 isslower in skin compared with other tissues.18 Theactivity of AQP3 has only been shown to beenhanced through the use of extracts of the herbAjuga turkestanica.19 A high-end line of skin careproducts includes A turkestanica as an active in-gredient. In the future, skin conditions caused byexcess or diminished hydration may be treatedthrough pharmacologically manipulating AQP3.

Sebum, the oily secretion of the sebaceousglands that contains wax esters, sterol esters,cholesterol, di- and triglycerides, and squalene,20

confers an oily quality to the skin and contributessignificantly to the development of acne. In addi-tion, sebum, which is an important source of vita-min E, is believed to provide cutaneous protectionfrom environmental factors, whereas low levels ofsebum have been cited as a potential contributingfactor to dry skin development.21 This theory hasnot found support, though, because low seba-ceous gland activity has not been demonstratedto promote the development of xerosis. Sebumproduction has actually been found to playa more convoluted role in the cause of this condi-tion. Previously, it has been speculated that se-bum has no impact on epidermal permeabilitybarrier function primarily because skin with fewsebaceous glands (eg, as in prepubertal children)displays normal basal barrier function.22 Pre-pubertal children between 2 and 9 years oldfrequently present with eczematous patches (pity-riasis alba) on the face and trunk that do notemerge with the onset of sebaceous gland activity.The pharmacologic involution of sebaceousglands with supraphysiologic isotretinoin dosesdoes not affect barrier function or SC lamellarmembranes.23–25 Similarly, using ether to denudethe skin does not interrupt SC function.

Baumann362

Although barrier function is not influenced bysebum levels, sebum may still contribute to theetiologic pathway of xerosis in individuals whohave dry, resistant skin (the DR type in theBSTI). Lipids from meibomian glands, which aremodified sebaceous glands located in the eyes,are known to stave off dryness by preventingthe evaporation of tears.26,27 Similarly, perhaps,sebum-derived fats may produce a lipid filmover the skin surface, thereby preventing TEWL.A recent study evaluating permeability barrier ho-meostasis and SC hydration in asebia J1 micewith sebaceous gland hypoplasia supports thistheory.28 The normal barrier function in these se-bum-deficient mice was attributed to consistentlevels of the three most important barrier lipids(ceramides, free sterols, and free fatty acids)and the persistence of normal SC extracellularmembranes. The investigators observed, how-ever, that the asebia J1 mice exhibited dimin-ished SC hydration, suggesting that although anintact intercellular membrane bilayer system suf-fices for permeability barrier homeostasis, it doesnot necessarily contribute to normal SC hydra-tion. The researchers found that topically apply-ing glycerol restored normal SC hydration. Innormal skin, sebaceous gland–derived triglycer-ides are hydrolyzed to glycerol before transportto the skin surface. In individuals who are sebumdeficient, xerosis may be allayed by replacingthis glycerol. The acceleration of SC recoveryhas also been shown to be successful with theuse of glycerol.29

Reduced sebum production is rarely the sourceof patients’ complaints, but elevated sebum pro-duction, rendering oily skin that can lead to acne,is a common complaint. The age-related trajectoryof sebum production is well known. Sebum levelsare typically low during childhood, increase in themiddle to late teens, and remain relatively stablefor decades until decreasing in the seventh andeighth decades as endogenous androgen produc-tion declines.30 Other factors also have an impacton the level of sebum production. One’s geneticbackground, diet, stress levels, and hormonelevels affect sebum production. A fascinatingstudy of 20 pairs each of identical and nonidenticallike-sex twins revealed nearly equivalent sebumexcretion rates with significantly divergent acneseverity in the identical twins, but significant differ-ences in both parameters among the nonidenticaltwins, suggesting that both genetic factors andenvironmental factors had an impact on acnedevelopment.31 The use of oral retinoids to shrinksebaceous glands is well established, but topicalretinoids have not yet been shown to have thiscapacity. In addition, no other topical formulations

have been demonstrated to reduce sebumproduction.

Skin Care for the Oily–Dry Parameter

Skin that falls in the middle of the oily–dry contin-uum can be best characterized as manifesting anintact SC and barrier, normal levels of NMF andhyaluronic acid (HA), normal AQP3 expression,and balanced sebum secretion. Whether or notacne develops from it, elevated sebum secretionis usually responsible for placing skin on the oilyside of the oily–dry spectrum. The BSTI profilefor oily skin accompanied by acne is OS, becauseacne-infiltrated skin is distinguished by heightenedsensitivity (see later discussion). For individualswho have OS skin, treatment should focus onreducing sebum levels with retinoids, eliminatingor decreasing skin bacteria with antibiotics, ben-zoyl peroxide, or other antimicrobials, and usinganti-inflammatory ingredients. Treatment of oilyskin without acne—an oily, resistant (OR) type inthe BSTI—should be tailored to reduce sebumproduction, unless other parameters, such asdyspigmentation and wrinkling, are factors (seefollowing sections). Sebum secretion has beeneffectively decreased with the use of oral ketoco-nazole and oral retinoids,32,33 but such resultshave not yet been seen with topical products.The sebum in OR skin can also be camouflagedusing sebum-absorbing polymers and talcs.

Dry skin chronically exposed to the sun is likelycharacterized by an impaired skin barrier and re-duced NMF. Therapy for such skin should focuson skin barrier repair and reducing sun exposure,avoiding the sun if possible or at least providingadequate sun protection.

All patients who have xerosis should abstainfrom using harsh foaming detergents (found inlaundry and dish cleansers along with body and fa-cial cleansers), which remove hydrating lipids andNMF from the skin. Protracted bathing, particularlyin hot or chlorinated water, should also be avoidedby all patients who have dry skin (Box 1). For thosewho have very dry skin, humidifiers should be usedin low-humidity environments and moisturizersshould be applied two to three times daily andafter bathing.

In addition to pharmacologic products beneficialin the treatment of xerosis and practical recom-mendations regarding what patients who havedry skin should avoid, there are several over-the-counter (OTC) moisturizers (eg, occlusives,humectants, and emollients) available that are ef-fective in hydrating the skin (Table 2). Moisturizersare the third most often recommended type ofOTC topical skin care product.34 Awareness of

Box1Treatment suggestions for dry skin

How to treat dry skin

Preserve and replace skin lipids

Replace them in the proper ratio

Prevent loss of NMF

Increase function of AQP3

Glucosamine supplementation

Preserve and replace skin by

Avoiding

Detergents

Prolonged water immersion, especially inchlorine and hard water

Vigorously foaming cleansers

Surfactants (which may deposit fatty acidson the skin)

Using

Moisturizers containing fatty acids, ceram-ides, and cholesterol

For dry, resistant (DR) skin: Look for moistur-izers containing Ajuga turkestanica


the differences among moisturizer types is animportant part of a practitioner’s knowledge basefrom which to suggest the most suitable productsfor a given patient’s skin type. Moisturizers areusually packaged as water-in-oil emulsions (eg,hand creams) and oil-in-water emulsions (eg,creams and lotions).

OcclusivesWhen used in skin care products, occlusives,which are oily substances that can dissolve fats,coat the SC to inhibit TEWL. In addition to imped-ing TEWL, occlusives confer an emollient effect,and are therefore suitable products for treatingxerosis. The most effective occlusive ingredientsare petrolatum and mineral oil. Petrolatum, usedas a skin care product since 1872, is consideredone of the best moisturizers and a gold standardby which other occlusives are measured.35 A re-sistance to water vapor loss that is 170 timesthat of olive oil is ascribed to petrolatum.36 Unfor-tunately, petrolatum has such a greasy texture thatsome consumers find such products cosmeticallyunacceptable. Besides petrolatum and mineraloil, other frequently used occlusive ingredientsinclude paraffin, squalene, silicone derivatives(dimethicone, cyclomethicone), soybean oil,grapeseed oil, propylene glycol, lanolin, lecithin,

stearyl stearate, and beeswax.37,38 Derived fromthe sebaceous secretions of sheep, lanolin con-tains the important SC lipid cholesterol and cancoexist with SC lipids as solids and liquids at phys-iologic temperatures. Lanolin has been deemeda sensitizer by some, although it has beendemonstrated to be a weak allergen.39 Lanolinmay also be eschewed because it contains animalproducts. Although numerous moisturizers arenow labeled ‘‘lanolin-free,’’ lanolin is still widelyused. No occlusive ingredients provide long-last-ing benefits. TEWL returns to its previous levelonce the occlusive agent is removed from theskin. Occlusives are typically used in combinationwith humectants because decreasing TEWL bymore than 40% risks maceration, with elevatedbacteria levels.40

Propyleneglycol An odorless liquid with antimicro-bial and keratolytic properties, propylene glycol(PG) acts as an occlusive and a humectant. PGhas been shown to facilitate the cellular penetra-tion of some drugs, including steroids and mi-noxidil. PG is believed to be a weak sensitizer,but it may contribute to contact dermatitis by fa-cilitating the penetration of allergens into theepidermis.41

HumectantsHumectants are water-soluble and hygroscopicsubstances. Humectants applied to the skin havethe capacity to attract water from the externalenvironment (in conditions with at least 80%humidity) and from the underlying skin layers. Inlow-humidity conditions, however, humectantsmay absorb water from the deeper epidermisand dermis, thus contributing to TEWL and aggra-vating skin dryness.42 Consequently, humectantsare more effective when combined with occlusiveproducts. Several humectant products have alsobeen identified as exhibiting emollient characteris-tics.43 Humectants are incorporated into cosmeticmoisturizers because they prevent productevaporation and thickening, which prolongs theproduct’s shelf-life. These products do not impartlong-lasting antiwrinkle effects on the skin,however. Humectants, by drawing water into theskin, provoke a minor swelling of the SC, renderinga perception, which lasts for about 24 hours, ofsmoother skin with fewer wrinkles. Some humec-tants confer other benefits, such as bacteriostaticactivity.44 The most effective humectant ingredi-ents in skin care products are glycerin and glyc-erol. Several other compounds function as activehumectant ingredients, including alpha hydroxyacids, panthenol, carboxylic acid, sorbitol, sodiumhyaluronate, sodium and ammonium lactate,

Table 2Over-the-counter moisturizer types

Type Function Examples

Occlusives Coat the SC and reduce TEWL Lanolina

Mineral oila

Petrolatuma

Propylene glycolParaffinSqualeneDimethiconeCyclomethiconeSoybean oilGrapeseed oilLecithinStearyl stearateBeeswax

Humectants Attract H2O from outer theatmosphere and underlyingepidermis, hydrating the skin

GlycerinGlycerolPropylene glycolAHAs (glycolic acid, lactic acid)UreaSorbitolSodium hyaluronateSodium and ammonium lactateSodium pyrrolidineCarboxylic acidPanthenolGelatinHoney

Abbreviation: AHAs, alpha hydroxy acids.a These products also act as emollients.

Baumann364

sodium pyrrolidine, urea, propylene glycol, gelatin,honey, and other sugars.38 Effective moisturi-zers usually include occlusive and humectantingredients.

Glycerin A strong humectant, glycerin exhibitshygroscopic activity comparable to that of NMF.2

Investigators reported after a 5-year study com-paring two high-glycerin moisturizers to 16 otherpopular moisturizers used by 394 patients whohad severe xerosis that the high-glycerin productswere the most effective, quickly restoring dry skinto normal hydration with longer-lasting results thanthe other moisturizers, which included petrolatumpreparations.45 In addition, glycerin has beenshown, by way of ultrastructural analyses of skintreated with high-glycerin preparations, to expandthe SC by enhancing corneocyte thickness andproducing greater distance between layers ofcorneocytes.46 Glycerin has also been demon-strated to stabilize and hydrate cell membranesand the enzymes required for desmosomedegradation.45

Urea Since the 1940s, urea has been included inmany hand creams.47 This dynamic compoundis an end product of protein metabolism in mam-mals, the primary nitrogen-containing ingredientof urine, and an NMF constituent, and it displayshumectant and mild antipruritic properties.48

Combining urea with hydrocortisone, retinoicacid,49,50 and other ingredients has been shownto promote the cutaneous penetration by theseagents. The Cosmetic Ingredient Review ExpertPanel recently declared that urea does havethe capacity to enhance the percutaneous ab-sorption of other chemicals, and that urea issafe for use in cosmetic products.51 There hadbeen some earlier disagreement as to whetherurea had exhibited such activity. A double-blindclinical study comparing 3% and 10% ureacream found that the study formulations weremore effective in dry skin than the vehicle con-trol. The 10% cream reduced TEWL but the3% cream had no impact on TEWL, althoughthe creams were reported to be equallyeffective.52


Hydroxy acids Alpha hydroxy acids (AHAs) area class of naturally occurring organic acids thathave been found to function as humectants andexfoliants. The most frequently used AHAs inmoisturizing formulations are glycolic and lacticacids (derived, respectively, from sugar cane andsour milk). Other AHAs include malic acid, citricacid, and tartaric acid. Glycolic and lactic acidswere the first AHAs to become commerciallyavailable. It was shown more than 30 years agothat topical formulations containing AHAs exertsignificant effects on epidermal keratinization.53

A decade ago, glycolic acid was demonstratedto exhibit photoprotective activity.54 The onlybeta hydroxy acid (BHA), salicylic acid, which isderived from willow bark, wintergreen leaves,and sweet birch, acts as a chemical exfoliant andis included in synthetic form in various topicalpreparations.55 AHAs and BHA erode corneocytecohesiveness at the lowest levels of the SC, alsoinfluencing pH in the process, and break downdesmosomes, thus facilitating desquamation.56,57

Lactic acid This prominent AHA is unusual in that itis also a component of NMF. Lactic acid was firstused in dermatologic therapy in 1943 to treat ich-thyosis.58 In vitro and in vivo experiments havesince shown that lactic acid can enhance ceram-ide production by keratinocytes.59,60 In addition,a double-blind vehicle-controlled study using an8% L-lactic acid formula revealed that the AHAwas a superior treatment than the vehicle forphotoaged skin, rendering statistically significantimprovements in sallowness, skin coarseness,and blotchiness.61

EmollientsIncluded in cosmetics to hydrate, soften, andsmooth the skin, emollients are composed mainlyof lipids and oils. A smooth skin surface is ren-dered by these substances that act by filling inthe gaps between desquamating corneocytes.62

Emollient formulations enhance cohesion, yieldinga flattening of the curled edges of individual cor-neocytes.2 As a result, a smoother skin surface de-creases friction while improving light refraction.There are several classes of emollients, includingastringent, dry, fatting, and protective, along withprotein rejuvenators.38 There are also primarily oc-clusive ingredients that confer an emollient effect,such as lanolin, mineral oil, and petrolatum.

Moisturizers are generally regarded as safe,with reports of adverse effects exceedingly rare.Products containing preservatives, perfumes,solubilizers, sunscreens, and some other classesof compounds have been linked to reports of aller-gic contact dermatitis. Lanolin, propylene glycol,

vitamin E, and Kathon CG have been associatedwith contact dermatitis.63,64

Collagen and Polypeptide Ingredients

Most of the collagen ‘‘extracts’’ contained in manyexpensive moisturizers touted for replacing colla-gen lost with aging have a molecular weight of15,000 to 50,000 daltons, but only compoundswith a molecular weight of 5000 daltons or lesscan actually penetrate the SC.40 Nevertheless,the collagen and other hydrolyzed proteins andpolypeptides produce a temporary film on the epi-dermis that, once the product dries, fills in surfaceirregularities. A subtle stretching out of fine skinwrinkles is provided by the film created by theseproducts. This fuller or slightly plumper appear-ance can be further enhanced with the additionof a humectant. Formulations with collagen andpolypeptide ingredients confer little or no effecton TEWL, but are typically labeled as moisturizersand firming creams.

SKIN SENSITIVITYSensitive Versus Resistant

Resistant skin is characterized by a robust SC thatstrongly protects the skin from allergens and otherexogenous environmental irritants. Erythema andacne are rare in people who have resistant skin.Erythema may arise if an individual is overexposedto the sun; acne may emerge because of stress orhormonal fluctuations. Individuals who have resis-tant skin can use most skin care products withoutfear of adverse reactions (eg, acne, rashes, ora stinging response). The same qualities that allowfor such an advantage, however, also renderseveral products ineffective in such individuals,who have an exceedingly high threshold for prod-uct ingredient penetration and bioefficacy. Conse-quently, people who have resistant skin may beunable to detect differences among cosmeticskin care formulations because most productsare too weak to cross the potent SC to impartbenefits.

Sensitive skin is a more complex phenomenonand more difficult to characterize. It is also becom-ing increasingly common.65 Most patients whopresent to a dermatologist complaining of sensi-tive skin are healthy women of childbearing age.Fortunately, with age, the incidence of sensitiveskin seems to decrease. As the prevalence of sen-sitive skin has increased, so too has the number ofproducts marketed as suitable for the treatment ofsensitive skin. There are variations in the qualitiesof sensitive skin. There are four discrete subtypes:acne type (propensity to develop acne, black-heads, or whiteheads), rosacea type (tendency

Baumann366

toward recurrent flushing, facial redness, and ex-periencing hot sensations), stinging type (proclivityto experiencing stinging or burning sensations),and allergic type (prone to manifesting erythema,pruritus, and skin flaking). Each of these subtypespresents distinct treatment challenges to the prac-titioner because products designed and marketedfor sensitive skin are not necessarily appropriatefor all sensitive skin subtypes. Despite such differ-ences, the four subtypes of sensitive skin shareone significant feature: inflammation. One consis-tent focus in any sensitive skin treatment programtherefore is decreasing and eliminating inflamma-tion. For patients who present with more thanone type of sensitive skin, the treatment is under-standably more complex and challenging.

Acne Type

Although incidence and prevalence rates vary,acne is by far the most common skin disease, typ-ically affecting adolescents and young adults,equally by gender, between the ages of 11 and25 years. The second-largest demographic groupthat suffers from acne in appreciable numbers isadult women, who exhibit a hormonal componentto their acne. The pathogenesis of this conspicu-ous and, therefore, stressful condition originatesfrom the intersection of four main factors:increased sebum production; clogged pores dueto dead keratinocytes inside the hair folliclesadhering more strongly than in those withoutacne (higher sebum production may also promotesuch cellular clinging), the presence of the bacteriaPropionibacterium acnes, and inflammation.Although acne can occur in various idiopathicpresentations, the quintessential feature is the ad-herence of dead keratinocytes in the hair folliclesas a result of increased sebum production, yield-ing clogged follicles and the emergence of a pap-ule or pustule. Subsequently, P acnes migratesinto the hair follicle, intersecting with the collectedsebum and dead keratinocytes. This interactionspurs the release of cytokines and other inflam-matory factors that engender the inflammatoryresponse leading to the formation of the character-istic redness and pus. High levels of primarycytokines, chemokines, and other inflammatorymarkers are usually present in chronic inflamma-tory skin conditions such as acne.3

The treatment of acne targets the four primaryetiologic factors: reducing sebum production(with retinoids, oral contraceptives, or stressreduction), unclogging pores (with retinoids,AHAs, or BHA), eradicating bacteria (with benzoylperoxide, sulfur, antibiotics, or azelaic acid), anddecreasing inflammation.

Rosacea Type

According to the National Rosacea Society, 14 mil-lion Americans,66 usually adults between 25 and60 years of age, are affected by rosacea. Thisacneiform condition, the pathophysiology of whichhas yet to be completely elucidated, shares somesymptoms with acne, specifically facial redness,flushing, and papules; however, rosacea is alsocharacterized by the formation of prominent telan-giectases, the primary manifestation of the condi-tion. Topical rosacea treatments target the use ofanti-inflammatory ingredients to decrease thedilation of the blood vessels and the avoidanceof exposure to factors that trigger or aggravatesymptoms. The goal of rosacea therapy is toreduce vascular reactivity, attack free radicals orreactive oxygen species (ROS), inhibit immunefunction, and interfere with eosinophilic activity,degranulation of mast cells (which often colocalizeto areas of eosinophil-mediated disease), andthe arachidonic acid pathway. Eosinophils arepleiotropic multifunctional leukocytes involved ininitiating and promoting numerous inflammatoryresponses.67,68 The most effective anti-inflamma-tory ingredients (many of which are derived frombotanical origins) in the myriad topical rosaceatherapies include aloe vera, arnica, chamomile,colloidal oatmeal, cucumber extract, feverfew,licochalcone, niacinamide, Quadrinone, salicylicacid, sulfacetamide, sulfur, witch hazel, andzinc.69 Various prescription anti-inflammatoryproducts, including antibiotics, immune modula-tors, and steroids, are also available to treatrosacea.

Stinging Type

The stinging response is a nonallergic neuralsensitivity that some people experience in reactionto various triggers. Several tests are available toidentify ‘‘stingers’’ or the stinging tendency. Thelactic acid stinging test is a particularly well-regarded method of evaluating individuals whoreport invisible and subjective cutaneous irritation.The stinging sensation is not necessarily linked toerythema, because many patients feel stingingwithout manifesting redness.70 Rosacea patientsexhibiting facial flushing are more susceptible toexperiencing stinging caused by exposure to lacticacid.71 Patients who are confirmed to have thestinging subtype of sensitive skin should avoidtopical products containing the following ingredi-ents: alpha hydroxy acids (particularly glycolicacid), benzoic acid, bronopol, cinnamic acid com-pounds, Dowicil 200, formaldehyde, lactic acid,propylene glycol, quaternary ammonium


compounds, sodium lauryl sulfate, sorbic acid,urea, or vitamin C.

Allergic Type

A recent epidemiologic survey in the United King-dom found that over 1 year 23% of women and13.8% of men exhibited an adverse reaction toa personal care product (eg, deodorants and per-fumes, skin care products, hair care products, andnail cosmetics).72 Further, numerous studies haveshown that approximately 10% of dermatologicpatients who are patch tested for anywhere from20 to 100 ingredients manifest allergic sensitivityto at least one ingredient common in cosmeticproducts.70 The most common allergens are fra-grances and preservatives and the preponderanceof people who experience such reactions arewomen aged 20 to 60 years.73 Greater susceptibil-ity to allergic reactions is seen among those whoare overexposed to skin care products and pa-tients who have an impaired SC, as manifestedby xerosis.74

Based on the principles of the BSTI, people whohave oily, sensitive skin require oil control. Such anindividual would also likely require an acne or rosa-cea treatment regimen. Those who have dry, sen-sitive skin require treatment to achieve skin barrierrepair. People who have sensitive, wrinkled skinwould benefit from treatments intended to reducepresent wrinkles and prevent the formation of newones. Those who have sensitive, pigmented skintypically seek the removal of the pigmentary lesionand treatment to prevent additional pigmentation.

SKIN PIGMENTATIONPigmented Versus Nonpigmented

This skin parameter does not pertain to skincolor, but to the propensity to develop undesiredhyperpigmentations on the face, chest, or arms.Skin conditions or lesions that require excisionor treatment beyond skin care (eg, congenitalnevi, seborrheic keratoses) are not consideredwithin the realm of typical pigmented skin inthe BSTI framework. Pigmentary conditions orchanges that can be ameliorated with skin careproducts and minor dermatologic procedures,such as melasma, solar lentigos, ephelides, andpostinflammatory hyperpigmentation, do fallwithin this rubric, however. Some patients paysignificant sums in the pursuit of satisfactorytreatment of these anxiety-producing pigmentaryproblems; for practitioners to know how best totreat them, the origin of pigmentation should beclearly understood.

The skin pigment melanin is derived from the en-zymatic breakdown of tyrosine by tyrosinase into

dihydroxyphenylalanine and then dopaquinone,ultimately yielding the two melanin types, eumela-nin and pheomelanin.75 The more prevalent type,eumelanin, regularly correlates with the visualphenotype.76 More melanin is produced in dark-er-skinned individuals than lighter-skinned ones.The larger melanosomes in darker-skinned peopleaccommodate more melanin and thereforedecompose more slowly than in lighter-skinnedpeople.77 Melanin is synthesized by melanocytesand then transferred by way of melanosomes tokeratinocytes. Ultraviolet (UV) irradiation can alsoinduce melanogenesis, however, which underthese circumstances represents the skin’sdefense to the insult of UV exposure. In this reac-tion to UV irradiation, melanocytes accelerate theproduction of melanin and its transfer to keratinoc-tyes,78 resulting in the darkening of the skin inaffected areas.

One melanocyte is usually linked to approxi-mately 30 keratinocytes. In the process of transfer-ring through melanosomes, the melanocyte loadsthe melanosome with melanin and then attachesto the keratinocytes. The keratinocytes surroundthe melanosome and absorb the melanin afterthe protease-activated receptor (PAR)-2 isactivated.79 PAR-2, which is expressed in kerati-nocytes but not melanocytes, is a seven trans-membrane G-protein-coupled trypsin/tryptasereceptor activated by a serine protease cleavage.It is believed that PAR-2 regulates pigmentationby way of exchanges between keratinocytes andmelanocytes.80

The development of skin pigmentation can beinhibited by way of two main pathways: inhibitingtyrosinase, thereby preventing melanin formation,and impeding the transfer of melanin into kera-tinocytes. Effective tyrosinase inhibitors includehydroquinone, vitamin C, kojic acid, arbutin,mulberry extract, and licorice extract. Two pro-teins found in soy—soybean trypsin inhibitor (STI)and Bowman-Birk inhibitor (BBI)—have been iden-tified as agents that have the capacity to impedethe development of skin pigmentation. In additionto their depigmenting activity, STI and BBI havealso been demonstrated to prevent UV-inducedpigmentation in vitro and in vivo.81 STI and BBIimpart such effects by inhibiting the cleavageof PAR-2, and are therefore believed to affectmelanosome transfer into keratinocytes. This piv-otal transfer of melanosomes from melanocytesto keratinocytes has also been shown to beinhibited with the introduction of niacinamide,a derivative of vitamin B3.82 As the most effectivePAR-2 blockers, soy and niacinamide are theprimary agents for impeding melanin transfer tokeratinocytes.

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Within the two approaches to hindering melaninformation, there are three types of topical agentsuseful in exerting such influence. Besides the ty-rosinase inhibitors and PAR-2 blockers, exfoliatingagents, such as AHAs, BHA, and retinoids, canaccelerate cell turnover to such an extent that itoutpaces melanin production. Procedures, suchas microdermabrasion, and instruments, such asfacial scrubs, can also be used for these purposes.Any skin care regimen focused on reducing oreliminating the development of unwanted pig-mentation should also include the use of broad-spectrum sunscreens. Sun avoidance remainsthe most effective way to prevent pigmentarychanges to the skin, among other deleteriouseffects. In the BSTI, an individual who has a ten-dency to form unwanted dyschromias would beconsidered to have type ‘‘P’’ skin and, otherwise,type ‘‘N’’ skin.

SKIN AGINGWrinkled Versus Tight

Cutaneous aging is a dynamic, multifactorialprocess under endogenous and exogenous influ-ences. The etiologic factors have traditionallybeen considered so distinct that two discreteprocesses have been described: natural intrinsicaging is genetically driven, or cellularly pro-grammed, inevitable, and eventually results invisible skin alterations; extrinsic aging, whichalso manifests in cutaneous changes, resultsfrom the chronic exposure to various environmen-tal insults and is therefore avoidable. Recentinsights suggest that the primary factor implicatedin extrinsic aging—UV radiation—may actuallyalter the normal course of natural aging. If this isthe case, intrinsic and extrinsic aging are lessdistinct than previously believed.

This brief discussion considers these processesseparately. In recent years, the function of telo-meres, the specialized structures that protect theends of chromosomes, has come to be identifiedas one of the keys to intrinsic aging. Telomerelength is known to diminish with age, and this ero-sion is seen as tantamount to a gauge by which tomeasure chronologic aging. This veritable internalaging clock mechanism is the basis for one of thecurrently favored theories on aging.83 The enzymetelomerase, which stabilizes or lengthens telo-meres, is expressed in about 90% of all tumorsbut does not appear in many somatic tissues.83

This phenomenon implies that most cancer cells,unlike healthy cells, are not programmed for apo-ptosis, or cell death, essentially placing agingand cancer on opposite sides of the same coin.The epidermis is one of the few regenerative

tissues to express telomerase.84 Currently, notreatment options target telomerase becausecurrent data are insufficient regarding the safetyof extending telomere length.

Extrinsic aging, as implied in the definition, ispreventable and is thus subject to human control.Individuals can make a concerted effort to limit ex-posure to the primary causes of exogenous aging.These etiologic factors include smoking, otherpollution, poor nutrition, excessive alcoholconsumption, and especially solar exposure.Cutaneous damage results from exposure to UVirradiation through various mechanisms, includingthe formation of sunburn cells by way of pyrimidineand thymine dimers, collagenase synthesis, andthe promotion of an inflammatory response. Sig-nificantly, signaling through the p53 pathway aftertelomere disruption induced by UV irradiation(UVB in particular) has been linked to aging andphotodamage.85,86 Photoaging, photocarcino-genesis, and photo-immunosuppression are wellknown adverse effects of UV (particularly UVA),although much more remains to be learned aboutthe mechanisms through which UV irradiationfosters harmful effects.87 Because UV irradiationinhibits DNA and accelerates telomere shortening,this primary source of extrinsic aging can beconsidered to influence the course of intrinsicaging.

Rhytid formation, which begins in the lower der-mal layers of the skin, is the quintessentialmanifestation of aging skin. Few skin care productformulations can actually penetrate far enough intothe dermis to alter or reverse deep wrinkles, de-spite the wealth of products advertising otherwiseand the significant outlay of consumers’ money forsuch products. Antiaging skin care consequentlyfocuses on the prevention of wrinkle formation.88

Because it is well known that the three main struc-tural components of the skin—collagen, elastin,and HA—decline with age, the primary goal inproduct formulation is to prevent the degradationof one or more of these key constituents. Althoughthere are no topical products that can deliver thesesubstances deeply into the epidermis, despitewhat the marketing might indicate, some productsdo promote the natural production of these impor-tant compounds. Topically, retinoids, vitamin C,and copper peptide have been demonstrated tostimulate collagen production,89,90 and oral vita-min C is also believed to have the same capacity.91

In addition, retinoids have been demonstrated inanimal models to promote the synthesis of HAand elastin,92,93 whereas glucosamine supple-mentation is also believed to augment HA levels.94

As of yet, no products have been shown orapproved for the stimulation of elastin production.

Box 2Four elements of fundamental skin care

1. Mild cleansing

2. Hydrating

Effective moisturization (with humectantsand emollients)

3. Replenishing

With lipids, ceramides and fatty acids

4. Protecting

UV protection

Increased humidity


Another important target of wrinkle preventionthat occurs beneath the skin is reducing inflamma-tion, because inflammation is known to contributeto collagen, elastin, and HA degradation. Antioxi-dants play a significant role in this approachbecause they protect the skin by way of severalmechanisms that are becoming better understoodand elucidated. For example, ROS acting directlyon growth factor and cytokine receptors in kerati-nocytes and dermal cells can engender skininflammation. Nevertheless, much remains to belearned about the direct roles of growth factorsand cytokines in cutaneous aging. Currently,growth factors and cytokines are known to func-tion synergistically in a complex mechanism in-volving various types of growth factors andcytokines.95 It is believed that UV irradiation trig-gers a cascade of events, acting on growth factorand cytokine receptors in keratinocytes and der-mal cells, leading to downstream signal transduc-tion by activating mitogen-activated protein (MAP)kinase pathways (extracellular signal-regulatedkinase, c-jun N-terminal protein kinase, and p38).These then collect in cell nuclei, forming cFos/cJun complexes of transcription factor activatorprotein 1, and inducing the matrix metallo-proteinases collagenase, 92 kDa gelatinase, andstromelysin to break down collagen and othercutaneous connective tissue.96,97

The direct effects of ROS on the aging processand skin aging are more clearly understood.Kang and colleagues have shown that free radicalactivation of the MAP kinase pathways inducescollagenase synthesis, which leads to the break-down of collagen.97 Inhibiting these pathways bythe use of antioxidants is believed to deter photo-aging by preventing collagenase synthesis and itsensuing harmful effects on collagen. In experi-ments using human skin, Kang and colleaguesfound that the pretreatment of skin with the antiox-idants genistein and N-acetyl cysteine inhibitedthe UV induction of the cJun-driven enzymecollagenase.

A plethora of antioxidants are used as ingredi-ents in topical skin care products, including vita-mins C and E, coenzyme Q10, and those derivedfrom botanical sources, such as caffeine, coffeeberry, ferulic acid, feverfew, grape seed extract,green tea, idebenone, mushrooms, polypodiumleucotomos, pomegranate, Pycnogenol, resevera-trol, rosemary, and silymarin. Although copiousevidence is presented in the literature identifyingthe antioxidant potency of these ingredients, theirefficacy in topical formulations intended to combatthe cutaneous signs of aging has not yet been es-tablished. It likely that in the not-too-distant futuretechnological innovation in tissue engineering and

gene therapy will yield breakthroughs in the thera-peutic uses of growth factors, cytokines, andtelomerase.98 It is equally probable that somesuch applications will be included in the dermato-logic armamentarium. In the interim, several prac-tical steps can be taken to mitigate or even preventextrinsic skin aging, including: avoiding/limitingexposure to the sun (particularly from 10 AM to4 PM), using broad-spectrum sunscreen whenavoiding the sun is impossible, avoiding cigarettesmoke and pollution, taking oral antioxidantsupplements or topical antioxidant formulations,regularly using prescription retinoids, and eatinga diet high in fruits and vegetables. Protectingthe skin is a key step in fundamental skin care(Box 2).

SKIN TYPE COMBINATIONS AND CHANGES

Because the skin parameters together describethe simultaneous state or tendencies of the skinalong four different spectra, the permutations ofthe four skin parameters yield 16 different skintypes. The BSTI skin typing system can assist indi-viduals, once they have identified their skin type, ingaining insight into treating their particular skinproblem areas and provide guidance as to themost suitable OTC products for their skin. Forexample, an individual who has oily, sensitive,nonpigmented, wrinkled skin (the OSNW skintype) would be best served by using productswith retinoids and antioxidants. A person whohas dry, sensitive, nonpigmented, tight skin (theDSNT skin type), would be advised to use prod-ucts with ingredients intended for skin barrierrepair. Although the BSTI can provide significantguidance for one’s skin care choices, an individ-ual’s skin type can change, especially becauseof stress and exposure to variable environments(eg, when traveling to a region with a different cli-mate). This phenomenon should be considered

Baumann370

by patients and physicians in arriving at an overallskin type assessment. In addition, particular skinfeatures, proclivities, or manifestations are seenin certain skin types, which is important to ac-knowledge when using skin care products basedon the BSTI skin typing system. For instance,pigmented, wrinkled skin (PW) is more typical inan individual who has a significant history of sunexposure, resulting in wrinkles and solar lentigos.Dark skin is more common in individuals charac-terized as PT types; light skin is a common featureof those described as NW types. As for certain cu-taneous conditions, rosacea is observed in OSNWskin types more often than in those who have otherskin types. Eczema is more typical in people whohave the DS combination than in individuals whohave other skin types. Acne is associated withOS skin more than any other skin type.

SUMMARY

The categories used to describe skin types havechanged little over the last century, whereas theskin care product market has undergone rapidinnovation and exponential growth. The fourtraditional labels used to depict skin type cannotadequately characterize the actual variations ob-served in skin type nor provide sufficient guidancefor the proper selection of skin care products.There are four basic dichotomies or parametersthat more accurately characterize skin types andthese have only recently been introduced. By eval-uating skin according to these parameters—dry oroily, sensitive or resistant, pigmented or non-pigmented, and wrinkled or unwrinkled—andthus differentiating among the 16 permutations ofpossible skin types, consumers can more easilyidentify the most suitable topical treatments fortheir skin. An individual’s BSTI four-letter descrip-tive skin type is derived from answers to a 64-itemself-administered questionnaire. The BSTI isbased on the understanding that the variousparameters are not mutually exclusive; an individ-ual’s skin should be described along all four spec-tra simultaneously. Once armed with a patient’sBSTI score, physicians are equipped with signifi-cant information that can assist them in treatingnumerous skin conditions and confidently recom-mending the most appropriate OTC topical skincare products for their patients. Myriad topicalskin care products are available that can meetthe needs of most of the 16 skin types.

REFERENCES

1. Baumann L. The skin type solution. New York:

Bantam Dell; 2006.

2. Chernosky ME. Clinical aspects of dry skin. J Soc

Cosmet Chem 1976;27:365–76.

3. Elias PM. Stratum corneum defensive functions: an

integrated view. J Invest Dermatol 2005;125(2):

183–200.

4. Wildnauer RH, Bothwell JW, Douglass AB. Stratum

corneum biomechanical properties. I. Influence of

relative humidity on normal and extracted human

stratum corneum. J Invest Dermatol 1971;56(1):

72–8.

5. Orth D, Appa Y. Glycerine: a natural ingredient for

moisturizing skin. In: Loden M, Maibach H, editors.

Dry skin and moisturizers. Boca Raton (FL): CRC

Press; 2000. p. 214.

6. Rawlings A, Hope J, Rogers J, et al. Skin dryness—

what is it? [abstract]. J Invest Dermatol 1993;100:

510.

7. Ekholm IE, Brattsand M, Egelrud T. Stratum corneum

tryptic enzyme in normal epidermis: a missing link in

the desquamation process? J Invest Dermatol 2000;

114(1):56–63.

8. Elias PM. The epidermal permeability barrier: from

the early days at Harvard to emerging concepts.

J Invest Dermatol 2004;122(2):xxxvi–ix.

9. Scott IR, Harding CR. Filaggrin breakdown to wa-

ter binding compounds during development of the

rat stratum corneum is controlled by the water ac-

tivity of the environment. Dev Biol 1986;115(1):

84–92.

10. Sato J, Denda M, Chang S, et al. Abrupt decreases

in environmental humidity induce abnormalities in

permeability barrier homeostasis. J Invest Dermatol

2002;119(4):900–4.

11. Wang F, Feng XC, Li YM, et al. Aquaporins as poten-

tial drug targets. Acta Pharmacol Sin 2006;27(4):

395–401.

12. Sougrat R, Morand M, Gondran C, et al. Functional

expression of AQP3 in human skin epidermis and

reconstructed epidermis. J Invest Dermatol 2002;

118(4):678–85.

13. Takenouchi M, Suzuki H, Tagami H. Hydration

characteristics of pathologic stratum corneum—

evaluation of bound water. J Invest Dermatol 1986;

87(5):574–6.

14. Warner RR, Bush RD, Ruebusch NA. Corneocytes

undergo systematic changes in element concentra-

tions across the human inner stratum corneum.

J Invest Dermatol 1995;104(4):530–6.

15. Warner RR, Myers MC, Taylor DA. Electron probe

analysis of human skin: element concentration pro-

files. J Invest Dermatol 1988;90(1):78–85.

16. Warner RR, Myers MC, Taylor DA. Electron probe

analysis of human skin: determination of the water

concentration profile. J Invest Dermatol 1988;90(2):

218–24.

17. Ma T, Hara M, Sougrat R, et al. Impaired stratum cor-

neum hydration in mice lacking epidermal water


channel aquaporin-3. J Biol Chem 2002;277(19):

17147–53.

18. Yang B, Verkman AS. Water and glycerol perm-

eabilities of aquaporins 1-5 and MIP determined

quantitatively by expression of epitope-tagged con-

structs in Xenopus oocytes. J Biol Chem 1997;

272(26):16140–6.

19. Dumas M, Gondran C, Barre P, et al. Effect of an

Ajuga turkestanica extract on aquaporin 3 expres-

sion, water flux, differentiation and barrier parame-

ters of the human epidermis. Eur J Dermatol 2002;

12(6):XXV–VI.

20. Thiboutot D. Regulation of human sebaceous

glands. J Invest Dermatol 2004;123(1):1–12.

21. Clarys P, Barel A. Quantitative evaluation of skin

surface lipids. Clin Dermatol 1995;13(4):307–21.

22. Thody AJ, Shuster S. Control and function of seba-

ceous glands. Physiol Rev 1989;69(2):383–416.

23. Elias PM, Fritsch PO, Lampe M, et al. Retinoid

effects on epidermal structure, differentiation, and

permeability. Lab Invest 1981;44(6):531–40.

24. Gomez EC. Differential effect of 13-cis-retinoic acid

and an aromatic retinoid (Ro 10–9359) on the seba-

ceous glands of the hamster flank organ. J Invest

Dermatol 1981;76(1):68–9.

25. Geiger JM. Retinoids and sebaceous gland activity.

Dermatology 1995;191(4):305–10.

26. Mathers WD, Lane JA. Meibomian gland lipids,

evaporation, and tear film stability. Adv Exp Med

Biol 1998;438:349–60.

27. TiffanyJM.The roleofmeibomiansecretion in the tears.

Trans Ophthalmol Soc U K 1985;104(Pt 4):396–401.

28. Fluhr JW, Mao-Qiang M, Brown BE, et al. Glycerol

regulates stratum corneum hydration in sebaceous

gland deficient (asebia) mice. J Invest Dermatol

2003;120(5):728–37.

29. Fluhr JW, Gloor M, Lehmann L, et al. Glycerol accel-

erates recovery of barrier function in vivo. Acta Derm

Venereol 1999;79(6):418–21.

30. Pochi PE, Strauss JS, Downing DT. Age-related

changes in sebaceous gland activity. J Invest

Dermatol 1979;73(1):108–11.

31. Walton S, Wyatt EH, Cunliffe WJ. Genetic control of

sebum excretion and acne—a twin study. Br J

Dermatol 1988;118(3):393–6.

32. De Pedrini P, Rapisarda R, Spano G. The effect of

ketoconazole on sebum secretion in patients suffer-

ing from acne and seborrhoea. Int J Tissue React

1988;10(2):111–3.

33. Goldstein JA, Socha-Szott A, Thomsen RJ, et al.

Comparative effect of isotretinoin and etretinate on

acne and sebaceous gland secretion. J Am Acad

Dermatol 1982;6(Suppl 4 Pt 2):760–5.

34. Vogel CA, Balkrishnan R, Fleischer AB, et al. Over-

the-counter topical skin care products—a common

component of skin disease management. Cutis

2004;74(1):55–67.

35. Morrison D. Petrolatum. In: Loden M, Maibach H,

editors. Dry skin and moisturizers. Boca Raton

(FL): CRC Press; 2000. p. 251.

36. Spruit D. The interference of some substances with

the water vapour loss of human skin. Dermatologica

1971;142(2):89–92.

37. Draelos Z. Moisturizers. In: Draelos Z, editor. Atlas of

cosmetic dermatology. New York: Churchill Living-

stone; 2000. p. 83.

38. Kraft JN, Lynde CW. Moisturizers: what they are and

a practical approach to product selection. Skin

Therapy Lett 2005;10(5):1–8.

39. Kligman AM. The myth of lanolin allergy. Contact

Dermatitis 1998;39:103–7.

40. Wehr RF, Krochmal L. Considerations in selecting

a moisturizer. Cutis 1987;39(6):512–5.

41. Hannuksela M. Glycols. In: Loden M, Maibach H,

editors. Dry skin and moisturizers. Boca Raton

(FL): CRC Press; 2000. p. 413–5.

42. Idson B. Dry skin: moisturizing and emolliency. Cos-

metics & Toiletries 1992;107:69–78.

43. Del Rosso JQ. Cosmeceutical moisturizers. In:

Draelos ZD, editor. Procedures in cosmetic derma-

tology series: cosmeceuticals. 1st edition. Philadel-

phia: Elsevier; 2005. p. 97–102.

44. Mitsui T, editor. New cosmetic science. New York:

Elsevier; 1997. p. 134.

45. Orth D, Appa Y. Glycerine: a natural ingredient for

moisturizing skin. In: Loden M, Maibach H, editors.

Dry skin and moisturizers. Boca Raton (FL): CRC

Press; 2000. p. 217.

46. Orth D, Appa Y, Contard E, et al. Effect of high glyc-

erin therapeutic moisturizers on the ultrastructure of

the stratum corneum. Poster presentation at the

53rd annual meeting of the American Academy of

Dermatology. New Orleans (LA), February 1995.

47. Harding C, Bartolone J, Rawlings A. Effects of natu-

ral moisturizing factor and lactic acid isomers on

skin function. In: Loden M, Maibach H, editors. Dry

skin and moisturizers. Boca Raton (FL): CRC Press;

2000. p. 229.

48. Kligman AM. Dermatologic uses of urea. Acta Derm

Venereol 1957;37:155–9.

49. Wohlrab W. The influence of urea on the penetration

kinetics of topically applied corticosteroids. Acta

Derm Venereol 1984;64:233–8.

50. Wohlrab W. Effect of urea on the penetration kinetics

of vitamin A acid in human skin. Z Hautkr 1990;65:

803–5.

51. The cosmetic ingredient review (CIR) expert panel.

Final report of the safety assessment of urea. Int J

Toxicol 2005;24(Suppl 3):1–56.

52. Serup J. A double-blind comparison of two creams

containing urea as the active ingredient. Assess-

ment of efficacy and side-effects by non-invasive

techniques and a clinical scoring scheme. Acta

Derm Venereol Suppl (Stockh) 1992;177:34–43.

Baumann372

53. Van Scott EJ, Yu RJ. Control of keratinization with

alpha hydroxy acids and related compounds. I. Top-

ical treatment of ichthyotic disorders. Arch Dermatol

1974;110:586–90.

54. Perricone NV, Dinardo JC. Photoprotective and

antiinflammatory effects of topical glycolic acid.


55. Draelos ZD. Rediscovering the cutaneous benefits

of salicylic acid. Cosmetic Dermatology 1997;

10(Suppl 4):4–5.

56. Van Scott EJ, Yu R. Hyperkeratinization, corneocyte

cohesion, and alpha hydroxy acids. J Am Acad

Dermatol 1984;11:867–79.

57. Berardesca E, Distante F, Vignoli GP, et al. Alpha

hydroxyacids modulate stratum corneum barrier

function. Br J Dermatol 1997;137:934–8.

58. Stern E. Topical application of lactic acid in the treat-

ment and prevention of certain disorders of the skin.

Urol Cutaneous Rev 1943;50:106–7.

59. Rawlings AV, Davies V, Carlomusto M, et al. Effect of

lactic acid isomers on keratinocyte ceramide

synthesis, stratum corneum lipid levels and stratum

corneum barrier function. Arch Dermatol Res 1996;

288:383–90.

60. Harding CR, Bartolone J, Rawlings AV. Effectof nat-

ural mosturizing factor and lactic acid isomers on

skin function. In: Loden M, Maibach H, editors. Dry

skin and mosturizers. Boca Raton (FL): CRC Press;

2000. p. 236.

61. Stiller MJ, Bartolone J, Stern R, et al. Topical 8%

glycolic acid and 8% L-lactic acid creams for the

treatment of photodamaged skin. A double-blind

vehicle-controlled clinical trial. Arch Dermatol 1996;

132:631–6.

62. Draelos Z. Moisturizers. In: Draelos Z, editor. Atlas of

cosmetic dermatology. New York: Churchill Living-

stone; 2000. p. 85.

63. Gonzalo MA, de Argila D, Garcia JM, et al. Allergic

contact dermatitis to propylene glycol. Allergy

1999;54:82–3.

64. Baumann LS, Spencer J. The effects of topical

vitamin E on the cosmetic appearance of scars.


65. Draelos ZD. Cosmetic selection in the sensitive-skin

patient. Dermatol Ther 2001;14:194–9.

66. National rosacea society website. Available at: http://

www.rosacea.org/index.php. Accessed October 12,

2007.

67. Rothenberg ME, Hogan SP. The eosinophil. Annu

Rev Immunol 2006;24:147–74.

68. Shakoory B, Fitzgerald SM, Lee SA, et al. The role of

human mast cell-derived cytokines in eosinophil bi-

ology. J Interferon Cytokine Res 2004;24(5):271–81.

69. Brown DJ, Dattner AM. Phytotherapeutic

approaches to common dermatologic conditions.

Arch Dermatol. 1998;134(11):1401–4.

70. Basketter DA, Griffiths HA. A study of the relation-

ship between susceptibility to skin stinging and

skin irritation. Contact Dermatitis. 1993;29(4):185–8.

71. Lonne-Rahm SB, Fischer T, Berg M. Stinging and

rosacea. Acta Derm Venereol. 1999;79(6):460–1.

72. Orton DI, Wilkinson JD. Cosmetic allergy: incidence,

diagnosis, and management. Am J Clin Dermatol

2004;5(5):327–37.

73. Mehta SS, Reddy BS. Cosmetic dermatitis current

perspectives. Int J Dermatol 2003;42(7):533–42.

74. Jovanovic M, Poljacki M, Duran V, et al. Contact al-

lergy to Compositae plants in patients with atopic

dermatitis. Med Pregl 2004;57(5–6):209–18.

75. Freedberg IM, Eisen AZ, Wolff K, et al, editors.

Fitzpatrick’s dermatology in general medicine. 5th

edition. New York: McGraw-Hill; 1999. p. 996.

76. Wakamatsu K, Kavanagh R, Kadekaro AL, et al.

Diversity of pigmentation in cultured human melano-

cytes is due to differences in the type as well as quan-

tity of melanin. Pigment Cell Res 2006;19(2):154–62.

77. Szabo G, Gerald AB, Pathak MA, et al. Racial

differences in the fate of melanosomes in human

epidermis. Nature 1969;222(198):1081–2.

78. Hermanns JF, Petit L, Martalo O, et al. Unraveling the

patterns of subclinical pheomelanin-enriched facial

hyperpigmentation: effect of depigmenting agents.

Dermatology 2000;201(2):118–22.

79. Briganti S, Ottaviani M, Picardo M. Chemical, phar-

mologic, and physical agents causing hypomelano-

sis. In: Nordlund JJ, editor. The pigmentary system.

New York: Oxford University Press; 2006. p. 678.

80. Seiberg M, Paine C, Sharlow E, et al. Inhibition of

melanosome transfer results in skin lightening.

J Invest Dermatol 2000;115(2):162–7.

81. Paine C, Sharlow E, Liebel F, et al. An alternative

approach to depigmentation by soybean extracts

via inhibition of the PAR-2 pathway. J Invest Dermatol

2001;116(4):587–95.

82. Hakozaki T, Minwalla L, Zhuang J, et al. The effect of

niacinamide on reducing cutaneous pigmentation

and suppression of melanosome transfer. Br J

Dermatol 2002;147(1):20–31.

83. Boukamp P. Ageing mechanisms: the role of

telomere loss. Clin Exp Dermatol 2001;26(7):562–5.

84. Boukamp P. Skin aging: a role for telomerase and

telomere dynamics? Curr Mol Med 2005;5(2):171–7.

85. Kosmadaki MG, Gilchrest BA. The role of telomeres

in skin aging/photoaging. Micron 2004;35(3):155–9.

86. Kappes UP, Luo D, Potter M, et al. Short– and long-

wave UV light (UVB and UVA) induce similar muta-

tions in human skin cells. J Invest Dermatol 2006;

126(3):667–75.

87. Marrot L, Beladi JP, Meunier JR. Importance of UVA

photoprotection as shown by genotoxic related end-

points: DNA damage and p53 status. Mutat Res

2005;571(1-2):175–84.

http://www.rosacea.org/index.php




88. Baumann L. How to prevent photoaging? J Invest

Dermatol. 2005;125(4):xii–xiii.

89. Varani J, Warner RL, Gharaee-Kermani M, et al.

Vitamin A antagonizes decreased cell growth and

elevated collagen-degrading matrix metallo-

proteinases and stimulates collagen accumulation

in naturally aged human skin. J Invest Dermatol

2000;114(3):480–6.

90. Nusgens BV, Humbert P, Rougier A, et al. Topically

applied vitamin C enhances the mRNA level of colla-

gens I and III, their processing enzymes and tissue

inhibitor of matrix metalloproteinase 1 in the human

dermis. J Invest Dermatol 2001;116(6):853–9.

91. Kockaert M, Neumann M. Systemic and topical

drugs for aging skin. J Drugs Dermatol. 2003;2(4):

435–41.

92. Margelin D, Medaisko C, Lombard D, et al. Hyalur-

onic acid and dermatan sulfate are selectively

stimulated by retinoic acid in irradiated and nonirra-

diated hairless mouse skin. J Invest Dermatol 1996;

106(3):505–9.

93. Tajima S, Hayashi A, Suzuki T. Elastin expression is

up-regulated by retinoic acid but not by retinol in

chick embryonic skin fibroblasts. J Dermatol Sci

1997;15(3):166–72.

94. Matheson AJ, Perry CM. Glucosamine: a review of

its use in the management of osteoarthritis. Drugs

Aging 2003;20(14):1041–60.

95. Fitzpatrick RE. Endogenous growth factors as

cosmeceuticals. Dermatol Surg 2005;31(7 Pt 2):


96. Fisher GJ, Voorhees JJ. Molecular mechanisms of

photoaging and its prevention by retinoic acid: ultra-

violet irradiation induces MAP kinase signal transduc-

tion cascades that induce Ap-1-regulated matrix

metalloproteinases that degrade human skin in vivo.

J Investig Dermatol Symp Proc 1998;3(1):61–8.

97. Kang S, Chung JH, Lee JH, et al. Topical N-acetyl

cysteine and genistein prevent ultraviolet-light-

induced signaling that leads to photoaging in

human skin in vivo. J Invest Dermatol 2003;

120(5):835–41.

98. Ostler EL, Wallis CV, Aboalchamat B, et al. Telome-

rase and the cellular lifespan: implications of the

aging process. J Pediatr Endocrinol Metab 2000;

13(Suppl 6):1467–76.

Selling Skin CareProducts in your MedSpa
R. StephenMulholland, MD
KEYWORD� Skin care

The marriage of retail and medicine began itspopularity back in the 1990s. Since then, manyphysicians have been attracted to the allure ofunmanaged care, more money and the bindingloyalty created when a patient becomes the physi-cian’s consumer. Annually, the cosmetic industryin the United States nets $50 to $75 billion a year,and the allure of this retail market has brought fortha new wave of competitors: physicians. Now com-peting for the retail dollar of the consumer are notonly the mega-manufacturers like Lancome, Clini-que, and L’Oreal; every physician has a vast arrayof lotions and potions to cure and enhance cos-metic results. In fact, just his past year, one ofthe very first medical skin care product companies,Obaji, successfully completed an initial publicoffering and continues to trade well on NASDAQ.Many of these storefront medical clinics, nowtermed medical spas (medspas) offer a vast arrayof laser services, fotofacials, laser hair removal,fat reduction, cellulite treatment, leg vein therapy,chemical peels, injectable rejuvenation, and aneven larger selection of must-have medical skincare products. The term medical spa, an oxymo-ron. the word spa is an acronym of the Latinphrases ‘‘Salus Per Aquam’’ meaning healththrough water. Medspas offer little of the traditionalrelaxing treatments that have come to be knownand are now based more on obtaining resultsthan relaxation. I first started a medical spacalledSpaMedica, back in 1997 and adopted and trade-marked the name as I felt it represented the mergerof the customer service commitment and experi-ence of the day spa with the biological credibilityand outcomes of medicine. In reality, the ‘‘nopain, no gain’’ principle applies to most of theseservices. This niche market was created by the

SPAMEDICA, First Canadian Place, 100 King Street West, 2E-mail address: [email protected]


demand of consumers to receive treatments thatdeliver results in a retail environment of awesomecustomer service. The consumer no longer wassatisfied with a few creams and some steamapplied by a beautician. This new savvy individualwanted a treatment that delivers results and wasperformed by a licensed medical professional. Inan effort to enhance these results and achievethe goals of the patient, cosmeceuticals wereborn. What is a cosmeceutical? According to Wiki-pedia, ‘‘cosmeceuticals are cosmetic productsthat are claimed, primarily by those within thecosmetic industry, to have drug-like benefits. Theword is a portmanteau of the words cosmeticand pharmaceutical.’’ To many others in the cos-metics industry, it really has become somethingcloser to the ringing of a cash register. Cosmeticmanufacturers have figured out that it is to theiradvantage to create this new category betweencosmetic and pharmaceutical drug, as it is costlyto obtain US Food and Drug Administration (FDA)approval. Rather, these manufacturers placeclaims on their product to be medically effectivewithout leading the consumer to believe it isa drug. Is this truth in advertising or a play onwords? Frankly it is a combination of both. If soldto the consumer without proper consultation andcontinued follow-up, these cosmeceuticals areakin to every other topical beauty product on themarket. If one pair the cosmeceutical with the pro-fessional skill and knowledge of a medically trainedprofessional, however, the consumer is delivereda comprehensive service and takes home continu-ity of care that is unparalleled in the traditional spaindustry. This article explains the legalities of sell-ing retail products in the medical practice, how tosell effectively and profitably, how this will help

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retain clients and how to encourage those clientsto refer their friends with confidence, medical prac-tice and its retail mix. Welcome to the beginning ofyour journey into retail medicine.

REGULATORYOVERVIEW TO SELLING PRODUCTSAND SKIN CARE

In the current regulatory environment, cosmeceut-ical manufacturers can mislead the consumerthrough advertising that suggests that the productis as effective as a medication. Wrinkle, cellulite,and stretch mark reduction or improvementcreams are commonplace in the nonphysicianmedical retail market. Consumers are led tobelieve that the same testing and rigorous controlsthat are required by the FDA for medications haveto be performed on the cosmeceutical product. Inactual fact, the FDA and the Food and Drug Act donot recognize any product class as cosmeceuti-cals. Therefore a product is a drug, a cosmetic,or a combination of both, but the idiom cosme-ceutical has no legal significance.

The FDA states that:

‘‘Food, Drug, and Cosmetic Act defines drugsas those products that cure, treat, mitigate, orprevent disease or that affect the structureor function of the human body. While drugsare subject to an intensive review andapproval process by FDA, cosmetics are notapproved by FDA before sale. If a producthas drug properties, it must be approved asa drug.’’

Cosmeceutical manufacturers avoid legalactions and investigation by the Federal TradeCommission by labeling the products clearly andavoiding statements that point toward the proper-ties and intended effect of a medication. If themanufacturer wants to make claims regardingthe affect of the product on the structure or func-tion of the human body, such claims must besubstantiated by scientific evidence. This processof review, investigation, and approval is costly andtime-consuming. If the product is not recognizedas a drug then it may be rendered as legallyunmarketable.

Legally speaking, the difference between a cos-metic and a drug is the product’s intended use, asthe laws and regulations differ for to each typeof product. The Food, Drug and Cosmetic Actdefines cosmetics as

‘‘articles intended to be rubbed, poured,sprinkled, or sprayed on, introduced into,or otherwise applied to the humanbody.for cleansing, beautifying, promoting

attractiveness, or altering the appearance’’[FD&C Act, sec. 201(i)].

Listed in this group are:

MakeupPerfumesNail polishPermsToothpastesMoisturizers for skinLip-enhancing productsShampoosHair colorsDeodorants

The Food, Drug and Cosmetic Act defines drugsas:

‘‘(A) articles intended for use in the diagnosis,cure, mitigation, treatment, or prevention ofdisease.and (B) articles (other than food)intended to affect the structure or any func-tion of the body of man or other animals’’[FD&C Act, sec. 201(g)(1)]

There are some products that can be consid-ered both cosmetic and drug. These productsare not to be confused as cosmeceuticals butrather when a product has two defined intendeduses that fit into both the cosmetic and drug cate-gories. Some products listed in this category bythe Food, drug and Cosmetic Act are:

Antidandruff shampooDeodorants that are antiperspirantsAny product with a recognized sun-protection

factorFluoride toothpastes

Intended use is established in two ways: claimson the product label and claims in the advertising.These claims, depending on their content, maycause a product to be considered a drug, evenwhen the product is marketed as if it were a cos-metic, because the intended use is to treat orprevent disease or otherwise affect the structureor functions of the human body. Ingredients maycause a product to be considered a drug,because they have known and proven therapeuticaffects on the structure and function of the humanbody. Some examples of products in this cate-gory are:

Hair growth productsCellulite treatment productsWrinkle and stretch mark reduction productsVaricose vein treatment productsCellular rejuvenation productsFluoride toothpaste

Selling Skin Care Products in your MedSpa 377

The FDA does not have an approval system forcosmetic products or ingredients before they aremarketed to the consumer (with the exception ofcolor additives). Drugs, however, are subject toFDA approval. Drugs either must receive premar-ket approval by the FDA or conform to final regula-tions specifying conditions whereby they generallyare recognized, proven by data, as safe and effec-tive, and not misleading in their intended affect onthe function and structure of the human body.Examples of this are:

Acne medicationsDermatitis and psoriasis treatmentsDandruff treatmentsSunscreen

Although there are minimum good manufactur-ing practice (GMP) regulations for drug products,there are no regulations regarding the GMP ofa cosmetic product; it is important that practi-tioner’s medical skin care products are neithermisleading nor misbranded for their intendeduse. Practitioners must research the companiesfrom which they are purchasing and have themprovide data to support their product claims.Ensure the product line(s) chosen to recommendto patients are labeled according to cosmeticlabeling regulations and if they have drug claims,are labeled according to drug regulations, includ-ing ‘‘Drug Facts’’ labeling. Labels should be clearto the consumer, and drug ingredients must belisted alphabetically as ‘‘Active Ingredients,’’ fol-lowed by cosmetic ingredients, listed in order ofprevalence as ‘‘Inactive Ingredients.’’ All productsshould have a clear expiration date. Reputablemanufacturers are not shy to show practitionerstheir packaging facility. Research; ask questions,and get the data before committing to a productor product line. The time investment will preventlegal implications, patient complications, and dis-appointment from the consumer.

Now that cosmetics, drugs, and cosmeceuticalshave been defined, it is time to see how retailing tothe consumer is affected.

THE SCIENCE OF SERVICE AND THE ARTOF THE SELLING SKIN CARE PRODUCTS

Besides having a product or service to sell, it isimportant to realize one needs to know how tosell. Selling is not just about having the productor service, it is about knowing what to do wheninteracting with the patient face to face, on thephone, or over the Internet. What all three of thesemedia have in common is the ability to allow thepatient to say ‘‘no thank you.’’ This fear of rejectionoften keeps physicians from being confident sales

people. The fear of being perceived as pushy,manipulative, or the used car salesman preventsphysicians from offering that additional service orproduct. Up-selling seems like a dirty word, butis it? If one does not up-sell, offer a product oran additional service to a client, is the physiciansaving the patient money, saving his or her ego,or doing a disservice? The physician in fact is mak-ing decisions for the patient.

Allowing these negative and presumptuousideas to get in the way of selling is one way to en-sure one will not succeed. To put it simply, if onedoes not make the sale, one will not have the busi-ness, no matter how good the skin care productline is, how successful the practice is, or howmuch marketing and advertising have been done.

The best way to view selling effectively is tochange how one views sales. First, one mustchange the idea of sales to relationship manage-ment. This relationship management is the basisof any interaction the physician will have with a pa-tient. Whether one is consulting with the patient ona service or skin care product, one needs to man-age the relationship. The physician needs to fullyunderstand the patient’s aesthetic skin concerns,his or her ultimate goals of treatment with a skincare product, and then manage his or her expecta-tions. Additionally, one needs to foster and growrelationships with patients. What this means is,make the skin care product or service meet theneeds and expectations of the patient so both ofpatient and physician benefit from the sale. Thephysician wins the sale; the patient wins the bene-fit of expertise, product, and service. A benefit ofthis relationship management explained later onin this article is the plethora of referrals physicianswill get from a satisfied patient.

Building a relationship with patients does notmean one has to spend hours getting to knowthem and their families. It does mean knowingabout their motivations for having a service or buy-ing a product. I mean understanding their goals andmatching those goals to realistic service outcomesand products to enhance those results. If a patient’sgoal is unrealistic, be candid with him or her. Offerthe patient what can be delivered and be willing torefer him or her on to someone else, if that will beofbenefit. Wordofmouth travels fastwhena referralis satisfied. Patients are also loyal to the physiciansthey know and trust, returning to them month aftermonth, year after year. Allow patients to know whatthe practice stands for, what staff are expected todeliver to them, what skin care product line andservices one believes in and why. Let patients beginto see the physician as a person and less likea vendor. Following up on all patient purchases re-moves buyers’ remorse, allows the patient to ask

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questions, and shows them physicians care aboutthem, not just the dollars they pay to the practice.Follow-ups allow the relationship managementcycle to continue, as there is always a reason tostay in touch.

Building rapport in a short period of time is diffi-cult, but not impossible. One of the best ways toobtain pertinent details about a customer’s needsis to ask questions that elicit information, ratherthan a simple yes or no. Ask open-ended ques-tions. These questions usually begin with thefollowing: who, what, when, where, why, andhow. The patient’s response to these questionswill allow the physician an opportunity to discussthe appropriate skin care products and adjunctiveclinical service that will deliver the results thepatient is seeking. Most physicians are used toclosed-ended questions, as these facilitate a fasterresponse that is generally objective and not sub-jective. In relationship management one needsthe subjective responses to really get to knowwhat the patient is expecting from skin care prod-uct experiences or clinical service. Asking ques-tions does not mean making the patient feel likehe or she is being interrogated, but rather thatthe physician is listening to his or her concernsand are genuinely interested.

The most uncomfortable part of relationshipmanagement is when the patient says ‘‘no thankyou.’’ Aside from the obvious factor of limited funds,there are only three main reasons a patient will notproceed with a service or purchase a product:

The patient did not like the physician.The patient did not trust the physician.The product or service offered did not match

expectations or goals.

Hard to hear, I know, but very true. All of thismeans the physician did not build a relationshipwith the patient. Do not ‘‘throw the baby out withthe bathwater,’’ however; just revisit the consulta-tion. Did the physician listen or talk? Were open orclosed questions asked? Did the physician listenor hear what the patient was asking for? Whatwere the goals and expectations of the patient,and did they match what was offered? I guaranteesomething was missed and can be followed upwith another consultation, another opportunity toclose the relationship management circle andform a ‘‘win–win’’ with that patient. Although it istrue not every interaction made with a patient willbecome an immediate skin care product or clinicalservices sale, it is true that there will some deferredopportunities with patients if one continues tomanage those relationships and build their trust.

Do not think that the relationship managementprocess ends when the patient has said yes or

no to the product or service This is just the begin-ning. Now begins the follow-up. Every skin careproduct purchase and every interaction requirea follow-up. Remember the saying ‘‘every actioncreates a reaction?’’ Well, this is the same theory.Every interaction with a patient is another opportu-nity to follow up with him or her. The patient buysa product or service; call to see how he or she isenjoying the product or how the service was.This is particularly important with skin care prod-ucts, as consumers often use the product incor-rectly as first and following up with a phone callwill help correct any skin care misconceptions orproduct concerns and salvage the retail relation-ship. Similarly, when the patient calls to book anappointment, call them to confirm the appoint-ment. If a patient cancels an appointment,follow-up to see when if he or she wants toreschedule. Even passive interactions such asknowing birthdays or how long it has been sincepatients have been in is an opportunity to followup with a letter, a phone call, or an E-mail. Remem-ber, one’s medical skin care line and products aremeant to be a lifetime commitment. Keeping intouch means keeping in business.

MEDICAL SKIN CARE PRODUCTS THAT SELL

There are nine areas to consider when choosingmedical skin care line to carry and sell. This is aneasy process but requires time and dedication toperform the research needed to get the right an-swers. The choices available today are limitless,and the information available is confusing andoverwhelming at best. The best choice will bea product that compliments the physician’s prac-tice, enhances patients’ clinical service and skincare product results, meets the needs of patients,is something the physician believes in and, mostimportantly, is profitable. Whatever one chooses,the physician must know it and how it comparesto what the competition has. The six key factorsto consider are:

Marketability and competitionTrends versus simplicityProfitQualityConsumablePrivate label versus mega-brand

Marketability and Competition

The first thing to consider is who is the physician’smarket and why are they buying the medical skincare product, where are they buying similar prod-ucts, and from whom are they buying them. It does


not matter what a physician sells if patients are notin the market to buy it. This requires strategicallythinking who the target market is. Considergender, age, social demographic, and regionalethnicities. With knowledge of the target audience,physicians can assess and anticipate needs. Theproduct needs to appeal to the largest mass of tar-get patients for one to sustain a business. Market-ing to a small niche will give a small return on yourinvestment. A physician’s choice will not appeal toeveryone, but it should appeal to most potentialpatients in the target market. The choice shouldanswer the reason patients are buying the skincare product. The choice should reflect the placethe patient would buy the product and the personfrom whom they would purchase the product.

Trends Versus Simplicity

Physicians who sell what is popular or new willbecome ‘‘out of fashion’’ as trends change. It isimportant to consider timing in the market placeand to realize that one has to be at the beginningof a skin care product trend to cash in on ‘‘what’shot and what’s not.’’ It is more important to havea reliable focused product line mixed with freshnew trends. Keep patients informed of new skills,products, services, but always have a focusedbase of products that are consistent and deliverreliable results. Stable services and medical skincare products become the staple of businessand allow the trends to enhance practice. Keepa close eye on skin care product trends that willkeep things fresh for patients while consistentproducts and services offer them assurance inoutcomes and something to fall back on whenthe trend passes. Learning to pick a hot productor service trend before it becomes main streamis a valuable skill that comes from knowing one’smarket and patients well. One should keep his orher product offering focused when beginning. Ifone’s product line is simple, then marketing willbe focused on the needs of one’s target patientmarket, which will bring the most return on invest-ment. As one’s practice grows, the physician canadd new products to the existing mix; however,keep new products compatible with the needsand expectations of current patients. One wantsto attract new business but not at the expense oflosing current patient loyalty.

Profit

One will not be in business long if without makinga profit. Choose a medical skin care line that canbe sold allowing a comfortable return. This meanstaking into account not only the product cost butall of the overhead that goes into it. Overpricing

the retail mix will not help either. One has toknow the market value of the product and theexpense of it and then evaluate its profitabilitybased on realistic marketability. The strategy ofinflating the price to make a profit margin willonly work until the patient finds a better price atthe practice next door. The best products arethose that retail at reasonable marketability,provide value to patients, and produce a returnon investment.

Quality

Medical skin care products and service quality areextremely important and go hand in hand whenone’s reputation is on the line. Purchasing inferiorproducts or supplies to perform services invariablywill create patients whose expectations and goalsare not met. Match product quality with serviceand outcome quality for a fail-proof mix.

Consumable

Choose a medical skin care line with recurringsales opportunity. An item that is consumed ona regular basis is one way a physician can estab-lish long-term loyalty and continuity of salesvolumes. Selling super sizes and large formats isnot beneficial, as patients have no reason to returnfor a very long time. Remember, each opportunityto make contact with patients is another opportu-nity to expose them to another product or serviceyou are offering. Smaller quantities allow formore frequent purchase and clinic visits, allowingphysicians the opportunity to recommendrelated products and services and offer thosenew trendy items.

Private Label Versus Mega-Brand

Private labeling is the business of partnering witha company that already makes the product onewants but allows the physician to brand it himselfor herself. There are many advantages to this part-nership, the most obvious being the patient loyaltythat is created when the product is only availablethrough one source. The other advantage is thatprivate labeling usually allows for greater profitmargins, because there is no established marketvalue for the product. The down side is that oneis competing with brand names that are knownnationwide (Obaji, PCA, Procyte, Perricone, Murad,Brandt) and have limitless (or seemingly limitless)marketing and advertising dollars. These megabrands employ professional trend and marketconsultants who know the market demands beforethe consumer has time to think about what theywant. How? These companies make and set thetrends, telling consumers what they need and

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want. The one big advantage physicians have overthese giants is the relationship with their patients.

In the end, it is an individual decision to privatelabel a skin care line, carry a national brand, buya whole line, or carry a few select products fromeach line. The most important choice to makewill be the choice of due diligence. One mustknow the products, know the market, and believein one’s decision. If a physician has done his or herhomework, the sales will flow naturally.

THE PROCESS OF SELLING SKIN CAREIN THEMEDSPA

Selling skin care products or clinical services isleveraging client relationships, and one needs tooptimize the service and outcome experiences atall conversion contact points within the medspa.The selling process is comprised of the stepstaken to build the relationship needed to managewith patients. I have developed a proven formulafor sales conversions: the six stages of success.When selling skin care products or clinical ser-vices, the six conversion stages become integralto the long-term success of the skin care lineand medspa business. These stages are easy totrack and are a measurable means to gaugesuccess (Box 1).

Everyone has come across bad sales people. Toavoid this, educate physician and staff must beeducated. Be prepared to answer patient ques-tions, provide patients with solutions, and exceedtheir expectations. Loosely speaking, successfulrelationship managers know the steps to a saleand the ongoing maintenance of the patientrelationship.

The Meet and Greet

This is the opportunity to begin a relationship withthe patient. Ask open-ended questions, find outinformation about the patient and let him or herknow about the business. This is the evaluationprocess for both physician and patient, so it isimportant to present oneself and the practicewell.

Assessing the Patient’s Needs

Take time to evaluate the patient’s needs, goals,and expectations. Get a list of the patient’s skinhealth concerns and the goals he or she hasfrom a skin care line. Manage those expectationsby pairing the patient with products or servicesthat will match these expectations. Manage anyunrealistic expectations by being candid with thepatient and either referring him or her to anotherphysician who can meet his or here needs or by

suggesting a different goal. An example is a patientwho expects her postpregnancy belly fat toinstantly melt away with a cream. By suggestingminiliposuction or a tummy tuck, the physicianchanges the patient’s expectations of the creamand focuses her on the procedure that will deliverthe results she is expecting. Always underpromiseand overdeliver.

Skin Care Product Demonstration

This is where the physician can show knowledgeabout the skin care line, its features, and bene-fits. The features are the qualities that the prod-uct demonstrates; benefits are the ‘‘what is in itfor me’’ for the patient. Focusing on the benefitstells the patient how this product will meet his orher expectations and fulfill or enhance his or hergoals.

Conquering Objections

Objections can happen if one has not managedthe patient relationship well. Turn every objectioninto an opportunity to follow up. Never let a patientwalk out the door and not have a plan to contacthim or her again in the near future.

Preventing Buyers’ Remorse by Future Pacing

Preventing buyers’ remorse involves creating anemotional goal in the mind of the purchasingpatient, around which the client builds value intohis or her skin care product or clinical servicespurchase. It is common for any consumer tofeel remorse after spending money on any prod-uct if the acquisition of that product is not linkedemotionally to a significant and future benefit forthe consumer. For example, if the patient pur-chasing the skin care line from is getting readyfor a big family event, wedding, anniversary,reunion, or birthday, and the goal is to have herskin looking great for that event, then the retailpurchase of the skin care products is unlikely tostimulate any buyers’ remorse when the patienttakes the skin care products home. During theconsultation, work future pacing, by drawing at-tention to the client’s skin in relation to upcomingevents.

Closing

Assume the sale. Unless the patient has said no,he or she is agreeing to the purchase andunderstands that the physician has met his or herneeds. Use the language of the assumed salethroughout the skin care product selling exchange,such as: ‘‘While using this product you willfind’’.... ‘‘The skin care product will give you

Box1TheMulholland six conversion stages to success

Stage 1

Awareness: phone call

Needs: excellent marketing

Goal: $100 lead cost

External: advertising, print, broadcast,public relations consultant, communitypublic relations, B2B

Internal: invertising, ambassador coupons,newsletter and coupon

Stage 2

Phone call: consultation

Needs: excellent call management systemand response, staff bonus program

Goals: 70% plus conversion to positive lead,50% plus conversion to consultation

Client contacts physician by phone call orE-mail.

Standard E-mail response and try to gainphone call access

Client is greeted warmly on the phone(within three rings).

Client’s questions are answered,

Create excitement, personal prospective,and need.

Phone closure procedure:

Positive lead: gives demographic dataand can be data mined

1 Close to consultation: active

2 Gain demo data and mail out: passive

Dead lead: no information gained

Stage 3

Consultation: treatment

Need: employee incentivization program

Goal: 70% plus book to treatment and skincare product purchase

Stage 4

Treatment: maintenance package orprescription

Need: good treatments and outcomes, staffincentivization program

Document with picture presentation,maintenance program plan

Goal: 80% plus book maintenancetreatment or packages

Stage 5

Treatment or maintenance patient: otherservices

Need: active cross merchandising, employeeincentive program, and product knowledge

Goal: 80% cross-merchandising

Stage 6

Patient (any stage): word-of-mouth referral

Need: active word-of-mouth referral system

SpaMedica ambassador coupon program

SpaMedica staff ambassador program

Goal: 80% of clients refer more than twoclients per visit


this sensation or side effect’’...’’you will findthat the skin care products give you’’..

Follow up

Follow up with the patient to maintain a long-termrelationship that will assure a repeat consumer.Satisfied patients will send referrals. This impor-tant word of mouth is the best skin care productsales tool. Reward patients who do send referralsby providing them with a discount program onservices or products. Thank them when and letthem know their confidence is appreciated. Creat-ing a network through referrals forms a solidpatient base and a guaranteed income.

For most physicians, selling is challenging.When one starts looking at selling as relationshipmanagement and product sales as continuity ofcare, one begins to find the process not onlyeasy but enjoyable.

BUILDING PATIENT RETENTIONWITH THE SKINCARE LINE

Patient relationships and client retention areamong the medspa’s most valuable assets; how-ever they are often one of the most undervaluedassets too. Physicians who devote most of theirresources toward marketing to new patientsusually do so at the expense of retaining theirexisting patients. If a physician ignores his orher network of patients to obtain new ones, hisor her patient base will shop elsewhere for theirskin care products and ultimately, their medspaservices.

Every patient relationship is an asset and hasa economic value or lifetime market value (LMV).A patient’s LMV is calculated by taking the aver-age patient transaction amount and multiplying it

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by the number of transactions he or she willconduct with the practice over a period of time(usually 20 years).

For example, if the average patient spends$2000 worth of clinical medspa services and$500 worth of skin care products every quarterfor 20 years, then the average patient’s LMV is:$2500 � 4 5 $10,000 � 2 5 $200,000.

For every happy skin care client who hasbecome part of a physician’s retention programand are coming for repeat services and skincare products, there are ambassador opportuni-ties that will result in three word-of-mouth referralpatients per year. Each of the these word-of-mouth patients who were referred will spend$10,000 per year and send three of their friends.Very quickly, that one a happy skin care andmedspa client becomes $1 million in LMV.When staff starts to view each client as $1 millionin revenue, the approach to customer service willimprove.

How can one afford to lose this patient? Is it notworth marketing dollars to invertise to this patient?How does one market to this existing patientbase? How does one ensure that they comeback for 20 years?

DEVELOPA PATIENT RETENTION STRATEGYPatient Mail Out/E-Blast

Keep in contact regularly with patients by mailingthem or E-blasting them with specials, holidayor seasonal offerings, new skin care products,or procedures.

Ask for Patient Feedback

There are many points during the patient’s visitwhere one can ask for feedback and participationin quality assurance programs. During the in officevisit, have the receptionist give the patients com-ment cards to fill out. By filling these out, patientperceptions of the clinic can be discovered, andpatients have an opportunity to share their experi-ence. By writing a letter afterward, thanking themfor their feedback and attaching a gift certificatefor a nominal amount, physicians ensure that thepatient will feel valued and will be certain to visitagain soon.

After several appointments at the clinic, a mail-out feedback questionnaire that is more detailedthan a comment card is sent to the patient inreturn for a gift certificate. The patient is provideda prestamped envelope to encourage his or herparticipation in the quality assurance program.Patients like to feel they are contributing to theoverall well-being of the clinic and that they willbe heard.

Make Patients ‘‘Win:’’ Create a CustomerLoyalty Program

Patients like to feel good about their purchases.Patients also like to feel that their repeat business,skin care products purchases, and word-of-mouthreferrals will be appreciated and valued by theirmedspa. Take advantage of this by offeringpromotions of various kinds to get patients toengage in spending behaviors they feel goodabout. Create a loyalty, high spender programthat rewards high purchasers with value options.

These promotions include special patient dis-counts, loyalty programs, thank-you notes, news-letters, and birthday notes with gift certificates.Promotions encourage patients to do somethingthat makes them feel good. Retaining patientsmeans keeping in touch with them and ensuringthey remain active in the clinic.

Know Patients’ Anticipated Behavior Basedon Previous Behavior

Occasionally, patients express in words, if they arenot happy. Listen to what they are sayingnonverbally.

If, for example, a patient regularly makes a skincare product purchase of a particular cream every3 months but has not been in for 4 months, some-thing is wrong. Her latency, the number of daysbetween purchase events, has changed. This iswhere most clinics fail. One’s medspa operationsoftware must create call retention action listsdaily of patients who need to be called andreminded that it is time to schedule a repeat visitfor skin care product renewal or repeat clinicalbooster service. If one overlooks this opportunityto follow up with this patient, he or she may belost for good. This is an opportunity for thephysician to follow up and find out why he or shehas not returned. This will provide a chance towin the patient back, and an opportunity to solidifyhis or her loyalty as the follow up call will make himor her feel significant to the clinic.

Now, track new patients who come in once andmake one purchase only. If a patient has notreturned within the normal latency period fora new patient then that patient is are not satisfied.Follow up.

As can be seen, it is just as important to retainone’s existing patient base as it is to build newpatients. The patient database not only providesa reliable revenue stream but are an invaluablesource of new referrals.

Maintain high patient satisfaction and protectpatient relationships as satisfied patients area clinic’s most valuable asset.


BUILDINGWORD-OF-MOUTH SKIN CAREPRODUCT REFERRALS

Word-of-mouth referrals are an important way tocreate a strong network of patients. Most ofa practice can be built just on word-of-mouthreferrals, saving valuable marketing dollars. Onemust be able to effectively leverage each happyskin care product and service patient in a practiceinto three or more word-of-mouth referral pa-tients per year. To really take advantage of thisopportunity, one needs to think outside of thepatient database and one’s circle of family andfriends.

RECRUIT SUPPORTERS (THE BASICS OF WORDOFMOUTH)

Enlist the support of current friends, family, andfellow colleagues. Family and friends who usemedspa services will be strong advocates, refer-ring their friends and colleges. Keep in mind thesaying that we are all separated by only 6� ofseparation. Do not underestimate the powerof support from other physicians. A strong referralbusiness needs to be supported by reciprocalreferrals. Make sure to keep colleagues well-informed any service or product offerings areadded or changed. Make sure that those whomake referrals can speak knowledgeably andaccurately about the medspa’s medical skin careline and products, services, and qualifications.An uniformed referral can harm one’s reputation.

NETWORK AND THEN NETWORKMORE

Physicians should join professional associationsand local business clubs both related to theirarea of expertise and outside. Particularly helpfulare associations that allow one to acquire memberlists and participate in group lectures. Physicianswill get to know experts and colleagues who willrefer patients. Presentations and marketing effortswill allow other members to get to know and trustthe medspa physician, which will turn them intopatients. To get referrals, people need to likea physician and trust him or her because theyare putting their reputations on the line by referringpatients. To gain that type of trust, they need toknow a physician.

Be careful of clubs that have political overtones,as one may end up turning away some patientswho may not share those views or who feel pas-sionate about an opposing cause. Some not forprofit associations also can be viewed as a cheesyway of getting media attention instead of a sincereeffort to contribute to the community. Local andregional business associations will give physicians

an opportunity to network with other businessowners who may be interested in his or her skincare line or clinical services or know someonewho is. These relationships almost always resultin reciprocal referrals.

MAKE CURRENT CUSTOMERS AMBASSADORS

When a patient/client expresses satisfaction withthe skin care line and products or clinical services,ask for word-of-mouth referrals. There are manyways of doing this that do no appear to be pushyAfter every visit, thank the patient for his or hersupport and express interest in working with himor her again. Suggest that his or her friends wouldalso appreciate the opportunity to benefit fromskin care products. Encourage patients to referothers and reward them for doing so. This couldbe by means of a coupon or a gift card offeringthem a call to action value discount on their nextvisit. One also can offer patient ambassadorswho refer patients value recognition that doesnot require spending more in the medspa (dinners,show tickets, magazine subscriptions). Do not puta lot of restrictions on the reward and make sure itis simple for the patient to understand. Do not waitto see if the patient cashes in on the reward;instead, be proactive and call him or her. Followup by asking him or her when he or she is comingin for his or her discounted service. Sincerity willgo a long way.

BECOMING ONE’S OWN AMBASSADOR

Research opportunities to reveal professionalexpertise through free industry or communitypublications, radio, and television media. Offerfree presentations or articles on upcoming trends;suggest interviews and make known one’s prac-tice scope and retail products that deliver results.Make sure that information is relevant to lis-teners’/readers’/viewers’ interests and does notsound like a thinly veiled commercial for yourbusiness.

One never knows when there may be an oppor-tunity to generate a word-of-mouth referral. There-fore it is critical for each member of the staff tobecome familiar with the skin care product lineand to develop an elevator pitch, a short 2- to3-minute sales pitch of features and benefits ofeach service and for the skin care line.

It is important to always engage people withone’s skin care line and service mix. Ask to gettogether and talk with those in an occupationthat would have many similar patient demograph-ics with the medspa. Talk about referring patientsand forming a business-to-business relationship.

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Advertising costs even can be shared by forminga campaign together.

Getting referrals may seem a bit too salesmanlike, but remember, with shared demographicsnetworking is desirable for both parties. Nothingneeds to be promised other than a commitmentto provide a service to their referrals that willrespect their reputation.

Habits are hard to break so make one very smartbusiness habit. Promise to take time to meet withsomeone in a business to business capacity atleast once a week.

Word of mouth can be a strong marketing tool,but one has to implement it wisely, constantlywork on new business-to-business relationships,and remember to reciprocate the referrals to reallybenefit from it.

CROSS-MERCHANDISING ONE’S SKIN CARE LINE

Wikipedia offers this definition of cross-selling:‘‘the term used to describe the sale of additionalproducts or services to a customer.’’

Cross-merchandising is the process of cross-selling andup-selling a patient products andservices.

By cross-selling, one offers patients skin careproducts or services related to whatever they arealready buying, giving them a more comprehen-sive group of products or services. It can bedefined as simply as the cashier at McDonald’sasking ‘‘do you want fries with that?’’

All good retailers know this trick of satisfying thecustomer’s demand for the best experience byoffering related bundled items for that experience.A good retailer can increase the check average ofthe customer significantly by effectively cross-merchandising.

Up-selling positions higher-priced products ina good/better/best succession allowing thepatient to see that their treatments and productsare continually progressing. A prime example isthe information technology industry. This industrycontinually introduces software and hardwareupgrades that offer more options and the abilityto improve overall systems.

Both methods of encouraging patients to spenda little more can enhance revenue significantly.

Many physicians are concerned about beingconceived as pushy, or perhaps they are con-cerned about whether the patient can afford it.Do not be concerned. Limiting their choices andopportunity to enhance their outcomes by makingpresumptions and choices for them providesa disservice to patients. Better meeting their needswith additional medical skin care products andservices demonstrates that the physician is awareof their needs and cares about their satisfaction.

Here are some tips to help improve one’s cross-marketing success.

Natural Pairings

Many opportunities arise naturally. If one sells Bo-tox for a more youthful appearance, for example,one also can offer Soft Tissue Fillers, to smoothout fine lines and sculpt or define other areas,thus better achieving patient goals. To gain this ex-tra sale, one simply might have to mention that theother products or services are available and willassist the patient with better attaining his or heraesthetic objective. It is fortuitous that medicalskin care products are a natural paring for any ofthe skin rejuvenation therapies in the medspa,from microdermabrasion to photorejuvenationand fotofacial packages. During the purchase ofthese skin rejuvenation programs the features,advantages, and benefits of bundling the skincare products (increased efficacy of the aestheticresult, home maintenance, and protection of theinvestment) with the clinical service are presentedto the patient. Most patients are very receptive tothe concept of the skin care product line providinghome maintenance for the in-office services thatthe physician delivered.

Stay Relevant and Stay Related

If one suggests too many unrelated cross-marketing suggestions, the whole sale may belost. Offering acne-controlling lotion with acnetreatments is a good fit, but if one attempts tosell that patient eyelash curlers, body cream, andlaser hair removal all at once, the chances ofsuccess are much less likely. Patients do not seea relation between the items and therefore per-ceive that they are just being sold items withoutconsideration to their needs. Rather, offer someof these unrelated items once trust has beengained, and it can be brought up casually, ina conversation.

Display Expert Recommendations

One way to facilitate cross-marketing is to post theitem with a specific recommendation from a knownexpert in the field. An example would be ‘‘Dr. Mul-holland recommends home skin care productstogether with in-office IPL fotofacial proceduresfor the treatment of vascular lesions and sun dam-age.’’ These recommendations can come fromother patients as well, on mail outs or E-blasts.These can be patient testimonials: ‘‘ Liz Fairbanks,46, says that she has never has this many compli-ments on her beautiful skin thanks to our medicalskin care products.’’


Timing

In some cases, the best opportunity to cross-merchandise is while a patient is trying somethingout. If they come in for a fotofacial or chemical peelconsultation, one can recommend a combinationtherapy program of home skin care products andthe in-office clinical service, thus targeting theproblem with two different methods increasingthe probability of success.

Leveraging the Selling Potential of One’s WebSite and Printed Material

One’s Web site and printed literature should sug-gest complimentary skin care products or servicesthat naturally enhance the results of the treatmentor product about which patients are reading. Givea variety but do not overwhelm them with choicesand options. Keep it simple salesman (K.I.S.S).

Service Bundles

Bundling long has been used as a way to enticepatients to buy not just a single item or service,but an entire group or series of items or treatmentsthat go together. Offering a price break on pack-age deals will help close the sale. For example,many patients interested in purchasing an IPLphotorejuvenation series will be open to a bundleof the IPL fotofacials, skin care products, Botoxand fillers if there is a value- added discount ofthe bundle and if the perceived outcome is supe-rior. Staggered or financed payment options torelieve the financial burden also may assist thepatient in the final decision to upgrade his or heroriginal purchase.

The way one approaches the cross-marketing ofservices and products will determine success withthis modus operandi. Although a practice cansurvive on single services, it can flourish by capi-talizing on cross-merchandising opportunities.

ART OF THE CLOSE

It is relatively simple to explain the features andbenefits of something, but closing the sale isanother story altogether. Although this is not theeasiest part of the sales process, it is the mostrewarding and profitable. Therefore it is to the phy-sician’s benefit to do it well and to close at least80% of patient consultations for procedures,services, or the purchase of skin care products.Here are a few basic pointers to help expose thisprocess to its raw necessities.

Close from the Start

Begin with realistic outcomes that match patientexpectations. Pave the way for a smooth close

by building patients’ trust in physician and prac-tice. Do not hard sell, going for the sale withina few minutes. The cutthroat approach alienatesmany potential patients. Once they have left thepractice they are gone for good, and so are all theirreferrals. Use consultative selling, by offering thepatient skin care options and services thataddress accurately the patient’s presenting skinconcerns and goals. Provide patients with asmuch information as possible about the productor service. Let them know that their purchasedoes not end once they buy, but rather the prac-tice is built on follow-ups and support that is avail-able whenever they need it. Scheduled follow-upafter the first skin care product purchase is impor-tant to ensure that the client is applying the prod-uct properly and to assess the skin reaction to theproduct. Additionally, one’s recommendation canbe altered accordingly until the client is in a happyhomeostasis with each product in the skin careline. Once a consumer is happy with a skin careline, it is difficult to alter buying habits. By makingoneself available, patients will not feel the need togo somewhere else for convenience.

Recognize Who is Ready to Buy

As one seeks information from the patient, it is im-portant to listen for signs that he or she is ready tobuy.

A patient might indicate an inclination to pur-chase by asking questions about the skin careproduct or the buying process: ‘‘How long will ittake before I see results?’’ ‘‘What will this do tomy skin if I am tanning?’’ or ‘‘Can I change servicesin this package if I want to?’’ All of these commentshave one important thing in common; the patient isassuming that he/she has already purchased theitem. This is one of the best scenarios, becauseclearly, the patient wants the product but wantsconfirmation of something to prevent buyers’remorse. Buyers’ remorse is what happens whena patient purchases something and regrets it oncethey have had time to think or reevaluate his or herdecision to purchase. By confirming that the patientis purchasing something that matches his or herexpectations, one eliminates the reevaluation pro-cess. When physicians validate that their practiceprovides support and is available to patients when-ever they have questions or concerns, they reas-sure patients that they have invested in somethingthat will continue to meet their needs or will bealtered to meet those goals until they are satisfied.

When a patient gives this classic sign and aftertheir questions have been answered, ask themfor authorization. Pass the sales receipt or quoteover to them and say, for example ‘‘If you will

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just authorize this, I will start scheduling yourappointments for the series of treatments yourequire to treat your rosacea.’’ The word ‘‘autho-rize’’ is less threatening than the words ‘‘signhere’’ and is more definitive than asking thepatient’s permission to process the sale or askingwhen the patient wants to purchase.

Respond to Questions with a Return QuestionNot a Closed-End Answer

Patients’ questions should be replied to with an-other question, allowing the flow of conversationto continue. These return questions can close thesale in an assumptive fashion. For example,instead of answering the question, ‘‘Does thiscome in black?’’ with yes or no, one could ask,‘‘Would you like it in black?,’’ therefore, assumingthe sale if it is available in black. One could answerthe question about the latest technology withsomething like, ‘‘Would you like the latest technol-ogy available or would you be interested insomething else if it would better achieve youraesthetic goals more efficiently, thus saving youtime and money with better treatment results?’’

Everyone Likes Something Free

This approach is coined the puppy-dog close. Itreflects the attachment children develop toa puppy after keeping it overnight. This is seenvery commonly in the cellular phone industrywhere one receives a month of unlimited time.The idea is to get one attached to the product orservice and thus creating a need. Trials in theclinical setting can be a free service or samplesof a skin care product line. The try before youbuy strategy is effective but only with certain con-sumers and is not for those who lack follow-up. Ifthese freebies are not followed up on, one couldbe wasting time and resources, as the patientwill not be motivated to return to buy.

Suggest Specific Terms

Rather than asking whether the patient wants tobuy, suggest a specific purchasing scenario andthen ask if he or she agrees to it. For example, ‘‘I

will draw up 60 units of Botox which we can useto achieve a smoother, more rested appearanceat $12 per unit. Are there other goals you wouldlike to achieve?’’ By addressing three separatequestions: the number of units to be used, theprice of the treatment, and if all concerns havebeen addressed, the physician provides the pa-tient with an opportunity to clarify any concernsbefore proceeding. This is a technique akin tothe presumption sale but is slightly softer in itsapproach as the physician does not end it witha ‘‘yes I will buy or a no I won’t buy’’ question.The physician closes the sale with a reciprocalquestion of affirmation for the sale.

Alternative Closing

When closing the sale, consider offering alterna-tives. This is a slight variation on the presumptionclose as one still assumes the patient wants theitem; however alternatives are offered based onpreference. Patients feel empowered when theyhave choices. Physicians can use this to their ad-vantage by saying, ‘‘Which of these would you like,the lighter weight sunscreen with pigment for thathealthy glow without tanning, or the heavier pro-tection sunscreen that provides a full-spectrumblock?’’ With this close, you are likely to makethe sale either way. Even if one is selling a singleskin care product or service, choices of dates,times, and payment options still can be offered.This differs from the classic presumption sale,which sometimes can sound ignorant, arrogant,or pushy.

Understanding when it is time to close a saleand what techniques should be used takes timeand experience. Remember, the close is the endof the selling process, but it is the beginning ofbuilding a lifelong patient relationship.

One’s skin care line should serve as an impor-tant vehicle for introducing one’s medspa busi-ness and its services to the consumer, and theskin care line should act as the anchor for patientretention, ambassador programs, and repeatedbuying decisions.

Good luck!

Medical ^ LegalConsiderations in theMedical Spa Environment
David J. Goldberg, MD, JD
KEYWORDS� Legal � Medical spa � Negligence

When one considers the procedures that can beperformed in the medical spa environment, itshould come as no surprise that the number ofnewly opened medical spas increases yearly.When one considers the medical–legal issues(and their impact on the business aspects) of themedical spa environment, it should also come asno surprise that the number of newly closed med-ical spas also increases yearly. A better under-standing of the medical–legal considerations ofthe medical spa environment plays a role in pro-moting a successful medical spa. The medicalspa setting is ideal for the performance of proce-dures that are incisionless, provide minimaldiscomfort, create little to no skin wound, andare performed in less than 1 hour. The proceduresthat fit this model include those that promote anti-aging, those that lead to rhytid treatment, and hairremoval. In the future, there will be other proce-dures as well.

Traditionally, medical antiaging and rhytid treat-ments have been fairly aggressive. They have in-cluded a variety of ablative procedures, such asdermabrasion, deep chemical peels, and carbondioxide and neodymium:yttrium aluminum garnet(Nd:YAG) laser techniques. Such procedures,because they produce an open wound and pro-longed cutaneous erythema and have a risk ofinfection, are not ideal for the medical spa setting.

Newer nonablative procedures that do notcause an obvious wound are ideal in a medicalspa. Multiple treatments with the various nonabla-tive laser and light source technologies lead toimprovement in skin toning with a reduction ofmild wrinkles.

Skin Laser and Surgery Specialists of New York and NewNY 10022, USAE-mail address: [email protected]


In addition to the various nonablative ap-proaches that improve collagen formation in theskin, botulinum injections that lessen wrinklescaused by hyperkinetic muscle tone and thewide gamut of available FDA-cleared filler agentsare part and parcel of any successful medical spa.

Nonablative techniques, in addition to botulinumtoxin and filler agents, can dramatically improveskin quality, can be done is less than 1 hour, andproduce no significant visible wound. They areideal for a high-quality medical spa.

Growing patient interest in the power of cos-metic interventions has led to an exponential risein cash flowing into the market for fillers, lasers,and botulinum toxin injections.1 This phenomenoncoincides with advances in the science of agingand the growth of the medical spa environment.2

Because the medical spa environment is almostexclusively a fee-for-service business, medicalspas are considered by business-oriented physi-cians to be the golden egg. Where money goes,legal questions often follow.

In addition to antiaging and rhytid treatments,laser hair removal has become a commonly per-formed procedure in nearly all medical spas. Inthe United States, over 10 million women spendmore than $3.5 billion for laser/light-source hairremoval. The number of women seeking hairremoval exceeds the number of men by 3 to 1.With the current popularity of laser hair removal,an increasing number of men are seekingtreatment.

There are many different lasers and laser-likedevices that are effective at removing unwantedhair. They include alexandrite, diode, Nd:YAG

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lasers, and intense pulsed light sources. Severalmanufacturers make each type of generic system.Except for darker skin types that are ideally treatedwith an Nd:YAG laser but may be treated withsome diode lasers, all of the previously mentionedlasers have been successfully used to removepigmented terminal hairs.

Experience leads to the best results. Some med-ical spa providers are well experienced; others arenot. Risk and resultant complications are oftenrelated to the experience of the medical spa physi-cian or, more commonly, of the physician extender.

There are more than 6500 spas in the UnitedStates. In a recent survey, 5% of these genericspa owners said they intended to add laser hairremoval to their list of provided services over thenext year. Laser hair removal treatments areexpected to double over the next 5 years. All med-ical spas provide such services. In the spa setting,there have been some well publicized complica-tions, with resultant malpractice lawsuits. Callingsuch a center a ‘‘medical spa’’ does not negatethese concerns. Because of these problems, stateregulatory organizations and several medicalsocieties have seriously looked at these trends.

The American Society for Dermatologic Surgeryrecently conducted a survey of its member derma-tologists. Forty-five percent of the reportingphysicians had seen nonphysician-induced com-plications from one or more of the previouslymentioned procedures. There has been significantrecent media concern about these problems.Because of the increasing concern about nonphy-sician performance of cosmetic procedures, theAmerican Academy of Dermatology, the AmericanSociety for Dermatologic Surgery, and the Ameri-can Society for Lasers in Surgery and Medicinehave recently published guidelines. The guidelinesmandate that under appropriate circumstances,and in accordance with state regulations, physi-cians may designate some cosmetic treatmentprocedures to certified or licensed nonphysicianpersonnel. The physician must be on site and beimmediately available. Some states allow nonphy-sicians to perform these procedures, others haveno current regulations, and others prohibit anyperson other than a physician to perform cosmeticlaser procedures.

The medical spa movement is growing. Withthe increasing elegant and simple proceduresavailable, the time is ripe for medical spa success.Along with the trend toward more medical spas willbe increasing government and medical specialtyconcern. The trend is toward more regulation,not less. When planning for the development ofa medical spa, all of these issues must beaddressed.

The most common medical–legal considerationin the medical spa environment relates tocomplications seen within this setting. These com-plications lead to the potential for medical mal-practice cases based on negligence.

NEGLIGENCE

Malpractice claims often arise from negligence.The proliferation of new laser technology andevolving medical indications and parameters fortreatment complicates the issue. Negligence cancome into question especially when physicianextenders, such as medical assistants and aesthe-ticians, perform laser treatments. The physician isresponsible for the employee performing the lasertreatments.

There are four required elements for a cause ofaction in negligence: duty, breach of duty, causa-tion, and damages.3 The patient bringing a caseagainst a physician must establish that her physi-cian had a duty of reasonable care in treating herand that he breached that duty. That breachmust also lead to some form of damages. Amere inconvenience to the plaintiff, such as mildswelling or echymosis, usually does not lead tophysician liability in a cause of action fornegligence. If the patient is unable to work forseveral days, she can report damages for theeconomic loss.

STANDARD OF CARE

The physician’s duty is to perform the cutaneouslaser procedure in accordance with the standardof care. When there is a breach in the standardof care that leads to damages, the laser operativemay be found negligent of committing medicalmalpractice. At the core of medical malpracticeis the concept of performing in accordance withthe standard of care of the reasonable personperforming that identical procedure. The lawexpects the cutaneous laser operator (physicianor nonphysician) to perform a laser procedure ina manner of a reasonable physician. This meansthe operator need not be the best in his field. Heneed only perform the procedure in a reasonablemanner.

How does the medical spa provider know whatis reasonable? The standard of care is not neces-sarily derived from some well known legal text. Inmost situations, the standard of care is neitherclearly definable nor consistently defined. It is a le-gal fiction to suggest that a generally acceptedstandard of care exists for any area of practice,especially in this field where so many lasers arenew to the marketplace.

Medical–Legal Considerations 389

To illustrate the standard of care in a malpracticecase, lawyers generally present laws, regulations,and guidelines for practice and for the medicalliterature, including peer-reviewed journal articles.Together, these materials help to show someconsensus about standard treatment. In addition,an expert’s view helps assemble a complete pic-ture. The standard in the medical spa environmentis no different from the standard of care of care anymedical office.

POLICYAND PROCEDURE

Physicians have put forth substantial effortstoward setting standards in treatment approachesand various conditions. Organizations such as theAmerican Academy of Dermatology, the AmericanSociety for Dermatologic Surgery, and the Ameri-can Society for Laser in Medicine and Surgery,provide position statements and practice guide-lines; however, guidelines do not represent law.

Although the scope of practice is typically de-fined by the state board of medicine, some legisla-tures have redefined the scope of practice so thatnonphysicians can perform cosmetic procedures.In California and Colorado, bills have been intro-duced in the legislatures recently that wouldhave allowed dentists to perform cosmetic facialprocedures. In the case of California, after pas-sage by the legislature, the bill was vetoed by thegovernor. The Colorado bill was passed by thelegislature and signed by the governor into law.In some states, nonphysicians have been giventhe right to perform certain cosmetic procedures,including laser hair removal and microdermabra-sion, without direct supervision by a physician.Such a situation, although perhaps financiallylucrative for some, may raise a variety of legalissues.

Clinical guidelines, such as who can and cannotdo procedures within a medical spa, can raisethorny legal issues.4 Although such guidelines donot represent law, they have the potential to offeran authoritative statement for the standard ofcare. Thus, a dermatologist or physician extenderworking for a dermatologist can use these to shieldthemselves from liability. Using guidelines as evi-dence of professional custom can be problematicif these guidelines are not necessarily consistentwith prevailing medical practice. In New Jersey,for example, only physicians may perform lasertreatments. In this case, the state law takes prece-dence over less-restrictive society guidelines.

Professional societies often attach disclaimersto their guidelines, thereby undercutting theirdefensive use in litigation. The American MedicalAssociation, for example, calls its guidelines

‘‘parameters.’’ The American Medical Associatio-nuses disclaimers stating that the guidelines arenot intended to displace physician discretion.

To assemble a complete picture, expertwitnesses also articulate the standard of care.The basis of the expert witness, and thereforethe origin of the standard of care, is groundedin the witness’ personal practice and the practiceof other experts the witness has observed inaction. Plaintiffs usually use their own expert, asopposed to the physician’s expert, to define thestandard of care.

Ultimately, the physician community establishesthat standard of care. For example, many physi-cians would say the safest technique for unwantedhair removal in darker skin types is the Nd:YAGlaser. However, a physician using a non-Nd:YAGlaser or light source that is approved by the FDAfor unwanted hair treatment in darker skin typesmay be performing laser treatment within the stan-dard of care. Many medical spas cannot afford twodifferent lasers, so they may purchase a diodelaser even though the Nd:YAG laser is viewed assafer for darker skin types. The diode laser iswithin the standard of care because it is approvedby the Food and Drug Administration for darkerskin types.

An example of where the standard of care wasbreached and a resultant medical malpracticecase followed was seen in New York where anesthetician in a medical spa used excessive ener-gies to treat a darker-skinned individual whodesired laser hair removal. The standard of caredictated using lesser energies; therefore, the stan-dard of care was breached. The resultant scaringwas permanent and represented the damagescause by the breach in the standard of care.

Another example involved a gynecologist whopurchased a skin laser to treat his female patientswho had spider veins on their legs. He purchasedthe appropriate laser and used appropriate treat-ment parameters. Because the skin can get hotwhen such lasers are used, the skin must be signif-icantly cooled during treatment. He did not knowthis, did not use cooling, and a patient wasscarred. This breach led to scarring—the damagerequired for a successful medical malpracticecase when the duty of using appropriate coolingwas breached.

In addition to the legal issues arising within themedical spa environment, a variety of ethicalissues may arise. A variety of cosmetics firmshave borrowed code words from medicine, suchas ‘‘clinical tests’’ and ‘‘dermatologist proven,’’that bestow scientific credibility on their product.These claims are often advertised by medicalspas. Product claims such as ‘‘71% of users

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noticed a reduction in the appearance of wrinkles’’are typical. To support this precise statistic, anadvertisement may note (in a smaller font towardthe bottom of the page), ‘‘In clinical tests underdermatologic control, the above results were con-firmed after 4 weeks of use.’’ Another productclaim states that the product offers ‘‘[d]ermatolo-gist proven results equal to a professional facialpeel.’’ It is unclear what ‘‘under dermatologiccontrol’’ or ‘‘dermatologist proven’’ means oreven if that matters, but it sounds scientific.Some companies use powerhouse advisoryboards of dermatologists.5 Should the consumerseeking treatment in the medical spa assumethat this board proved the efficacy of the product?Companies could provide such information ontheir websites. Secrecy about many studies thatpurport to prove a product’s effectiveness createsa dilemma—neither patients nor physicians canvalidate or analyze the data. Such is the typicalsituation of many products sold in the medial spa.

Under federal law, unsubstantiated claimsabout a skin-care product that stretch beyondpuffery may be illegal. The tenor of these adver-tisements invokes science, proof, and medicine.Consumers may realize that these claims areakin to a sugarless gum’s boast that ‘‘4 out of5 dentists surveyed’’ recommend their gum, butthe problem is far more pervasive in the antiagingindustry, and the targeted audience is all toowilling to suspend judgment because they havea great interest in erasing the signs of aging. Irre-spective of whether or not such claims are legal,exaggerated claims may be unethical.

WHAT IS REQUIRED

A simple action plan can help reduce the likelihoodof being sued in the medical spa environment.

Know state laws. Be certain your state allowsnonphysicians to perform noninvasivelaser procedures. You can contact your

state Board of Medical Examiners or hirean attorney to obtain this information.Know your state laws regarding physicianextenders. These state laws outweighmore liberal society guidelines.

Invest in training. Ensure that all members ofthe medical spa environment are ade-quately trained. This extends beyonda simple evening course. Invest in continu-ous training and live demonstrations.

Don’t be overly aggressive. Do the procedurein the same way as your peers.

Be honest with your patients. Communicaterealistic results with your patients. Com-munication skills help to keep patientshappy. Happy patients almost never sue.Training leads to experience. Experiencereduces the likelihood of lawsuits.

Knowing what requirements need to be fulfilledin a negligence case helps to prepare you in theunlikely case someone decides to sue. One cannever predict the outcome of a malpractice suit.A clear understanding of the aforementionedprinciples lessens the concern of medical–legalconsiderations arising within the medical spaenvironment.

REFERENCES

1. Misra VP. The changed image of botulinum toxin.

Br Med J 2002;325:1188–9.

2. Ringel EW. The morality of cosmetic surgery for

aging. Arch Dermatol 1998;134:427–31.

3. Furrow BF, Greaney TL, Johnson SH, et al. Liability in

health care law. 3rd edition. St. Paul (MN): West

Publishing Co.; 1997.

4. Hyams AL, Shapiro DW, Brennan TA. Medical prac-

tice guidelines in malpractice litigation: an early retro-

spective. J Health Polit Policy Law 1996;21:289–97.

5. Gross EA. Cosmetic surgery for aging is not inher-

ently immoral. [letter]. Arch Dermatol 1998;134:1294.

Medical Spa Marketing
Neil S. Sadick, MD, FAAD, FAACS, FACP, FACPha,b,*,Adam Dinkes, BA, MBAc, Larry Oskin, BSd
KEYWORDS� Medical spa � Medical spa marketing � Medical advertising� Direct mail marketing

Medical spas are different. We are not just sellingmedical and dermatology services; we are offeringclients viable new solutions to their skin care, bodycare, and hair care challenges. Traditional medicalmarketing becomes blurred today, as the expan-sion and acceptance of medical spas helpsyou to effectively compete with traditional skincare clinics, salons, and spas, while offeringmore therapeutic treatments from professionallylicensed doctors, nurses, aestheticians, massagetherapists, spa professionals, and medicalpractitioners.

MEDICAL SPAMARKETING: ONEWAYVERSUS NOWAY

There is no crystal ball with answers or magicalsolutions for creating your medical spa marketingstrategies, nor is there one way to do it right. Theonly wrong way is to do nothing at all, expectingnew staff and patients to magically walk in yourdoors each day. As medical spa doctors, owners,and managers, we must strategically create a mar-keting plan. This article shares some successfulideas to help you better market your dermatologyand medical spa services to your patients and toyour community.

Professional medical spas are rapidly becomingpopular; thousands are now opening here in NorthAmerica and across the globe each year. There aremore and more medical professionals switchingover to medical spas from traditional practices.The rules of marketing and advertising are

a Weill Medical College of Cornell University, New York,b Sadick Dermatology, 911 Park Avenue, Suite 1A, Newc Sadick Dermatology, Sadick Research Group, Sadick SkNY 10021, USAd Marketing Solutions, 10875 Main Street, Suite 205, Faiingsolutions.com)* Corresponding author. Sadick Dermatology, 911 Park AE-mail address: [email protected] (N.S. Sa


decidedly different, being much more relaxedthan what is required of a traditional medical prac-tice. Staffing and service requirements are differ-ent, and there are new options for how clientscan pay for these services. Because many medicalspa services are considered luxury services, theyhave more appeal than clinical treatments, andpatients are willing to pay for themselves, withoutinsurance.

Medical spas are now much more mainstreampopular with everyone from women, men, andteens to the Hollywood celebrities. There arecompetitive advantages and disadvantages. Thegood news is that more people are now aware ofthe unique benefits of professional medical spas.The downside is that you must make yourselfstand out by marketing yourself as a medical spaexpert. You must learn how to create an effectiveand coordinated marketing, advertising, promo-tional, and public relations (PR) campaign foryour medical spa.

DEFINE YOURMEDICAL SPA’S UNIQUESERVICE ADVANTAGES

Do you and your medical spa team have a series ofservices in which you specialize? Do you promoteyour expertise for these medical spa services asyour specialties? Do you know what your uniqueservice advantages are? There are skin careclinics, spas, dermatology centers, and salons onvirtually every street corner and in every shoppingcenter, office complex, and mall across the globe.

NY 10021, USAYork, NY 10021, USAincare, 911 Park Avenue, Suite 1A, New York,

rfax, VA 22030, USA (E-mail Address: LOskin@market

venue, Suite 1A, New York, NY 10021.dick).


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Sadick et al392

Everyone in town may offer traditional facial treat-ments. Not everyone may offer or be good at yoursignature facial treatments, laser hair removal,sclerotherapy, or other specialized services, how-ever. You create a marketing advantage by defin-ing your unique service advantages.

TOPMEDICAL SPA SPECIALTIES

This is a short list of some of the most popularmedical spa services. The list grows every dayas new technologies are offered and with theblending and blurring of multiple spa businesseswithin a medical spa. There is no traditionalmedical spa or cookie-cutter approach. Youhave the option to develop your own specialties.

Dermatology� Skin analysis� Skin rejuvenation� Signature facial treatments� Facial enhancements� Smoothing and contouring� Skin tightening

Cosmetic procedures� Breast augmentation� Breast lifts� Rhinoplasty� Blepharoplasty� Face lifts� Brow lifts� Liposuction/cellulite treatments� Body contouring� Mesotherapy/liposculpting� Mesolift� Thread lifts� Botox� Restylane

Specialized hair treatments� Hair loss treatments� Hair replacement treatments� Intense pulsed light/laser permanent hair

reduction treatments� Traditional hair removal services: sugar,

wax, depilatory, and threadMedical treatments and scientific skin care� Sclerotherapy� Spider/leg vein laser treatments� Ambulatory phlebectomy� Endovascular treatments� Specialized hand treatments� Microdermabrasion� Microcurrent� Micro laser skin peels� Acne light therapy� Red/infrared light therapy� Photodynamic light therapy� Photodynamic rejuvenation

� Cool touch treatments� Medical cleanse facials� Chemical and enzyme peels� Acne prevention/treatments� Antiaging treatments

Medical spa treatments� Massage therapies� Reflexology� Body wraps� Oxygen treatments� Vitamin therapies

Physiotherapies� Lymphatic drainage� Trigger point therapies� Scar tissue reduction� Exfoliation treatments� Detoxification treatments� Circulation stimulation� Sport rehabilitation

Special medical spa extras and options� Hair care and scalp therapies� Spa nail care� Prenatal/pregnancy therapies� Mineral makeup� Wedding makeup� Camouflage makeup� Eyelash extensions� Lash and brow tints� Makeup applications and lessons� Teeth whitening� Nutrition counseling� Yoga� Meditation� Chiropractics� Research and clinical trials� Comprehensive wellness therapies� Professional retail products: skin care,

hair care, body care, nutraceuticals andcosmeceuticals

THE ADVANTAGEWITHMANY NEW CHOICES

There are plenty of new choices for you and yourmedical spa patients. Although everyone seemsto understand what spas, dermatology centers,cosmetic surgery practices, and skin care clinicsare, you must help to clearly define the benefitsof your medical spa for your patients, your staff,and yourself.

Today’s spa clients and medical spa patientsare better educated than ever before, yet thereremain many mysteries that they need you toexplain. Because many of our professional ser-vices are performed behind closed doors, youmust become a market-driven medical spabusiness and not just a well-run operation. Notall medical spas are the same.

Medical Spa Marketing 393

MEDICAL SPAMARKETING BASICS

Your marketing strategy must be able to clearlydefine the benefits of your position, mission, andvision, so that you may become respected andknown as the best medical spa in town. Sit downwith your staff to write out your mission and visionstatements and plan to share them with yourpatients.

You must know exactly what and where you arenow and what and where you plan to be over thenext 5 years. These strategic business objectivesand goals must be facilitated through a well-supported marketing, advertising, and PRcampaign.

TaPro

Mo

Jan

Ma

Ma

Ju

Se

No

Example Mission Statement 1: Our mission atthe XYZ Medical Spa is to be respected asthe center of choice for our medicalpatients, professionals, and staff. Theneeds of our patients will always comefirst. We are committed to providing onlythe highest quality of personalized andcustomized care through state-of-the-arttechnologies, services, and products.

Example Mission Statement 2: Our mission isto have the XYZ Medical Spa proudlyrespected by you and all of our patients,medical professionals, staff, and our entirecommunity.

We will always deliver extraordinary person-alized and customized patient services.

We will always educate and inform ourpatients of every available service to sup-port their needs.

We will always provide exceptional qualitymedical and spa care services andproducts.

We will always maintain a safe environmentthat is special and caring.

We will only offer you the latest and mostappropriate state-of-the-art medical spatechnologies.

ble1motion options

nthMedicalTreatmentsandTherapies

uary/February __________________

rch/April __________________

y/June __________________

ly/August __________________

ptember/October __________________

vember/December __________________

MARKETING CALENDARS

Take the time to define an annual calendar strat-egy for specific medical spa promotions andservices you want to promote through the year.We suggest that you facilitate bimonthly promo-tions, taking into account the various seasonsand holidays throughout the year. List up to threepromotions per bimonthly period. If needed, cre-ate an Excel spreadsheet or a computerized graphthat lists all of the potential options (Table 1), andattempt to promote each of your special medicalspa services and treatment areas at least onceper year.

LOGOS AND CORPORATE IMAGERY

You should have a professionally designed logocreated for you. It is important to consistentlyuse this logo with your corporate colors through-out all of your signage, stationery, advertising,marketing, graphic design, PR, Internet, and Website programs. If you do not have a beautiful logoand icon image developed, hire a local graphicdesigner.

MEDICAL SPA BROCHURES AND SERVICEMENUS

You may already have a traditional and beautifulmedical spa service menu to share with your pro-spective patients. Many of you probably also haveextra tri-fold brochures from the technology,service, and product companies with which youare affiliated.

Your medical spa service menus should defineall of your comprehensive medical spa servicesand specialties, while carefully, yet briefly, listingall the benefits and features. It is important toshare these details for numerous reasons. First,many prospective clients do not know the benefitsof your medical specialties and spa services. Sec-ond, your service menu helps you sell moreservices to your existing patients. Third, this

SpaTreatments Retail Programs

__________________ __________________

__________________ __________________

__________________ __________________

__________________ __________________

__________________ __________________

__________________ __________________

Sadick et al394

critically important marketing device effectivelyhelps to present you to the local media.

This service menu can have prices printed withthe design or they can be offered as a separateslip-in sheet. Research has proved that your pa-tients spend more if they know the potential bene-fits and cost implications. Without these details,the ‘‘fear factor’’ takes over. Most people areafraid to ask how much your services cost. Manymedical spa services and treatments requirelong-term care, so your service menus shouldalso present the a la carte services and the variouspackage options. You can note that all serviceprices are based on a professional and personalconsultation. Further, you should devote at leastone page to Spa Courtesies, wherein you clearlydefine your hours, payment terms, appointmentguidelines, cancellation policies, and so forth.

Should you have special services and cate-gories, you may even want to consider creatinga separate menu dedicated to each of your profes-sional services and areas of expertise.

Finally, be sure to embellish this spa servicemenu with photographs of your key medicalprofessionals and some of your services. Showsome of your best makeovers. If needed, usestock photographs as illustrations. A picture is stillworth a thousand words.

MEDICAL SPA PRICING STRATEGIES

You must analyze your own marketplace beforeyou begin to successfully and competitively pro-mote your medical spa services. With higherprices comes respect for you and your staff, whileyou must maintain credibility. Do not worry toomuch about being competitive with all of the plas-tic surgeons, dermatologists, aestheticians, sa-lons, spas, and massage therapists in town.There is no need to worry about discounts or beingthe cheapest in town. In fact, we recommend thatyou may want to be marketed at above average tothe highest-priced services in town. Your advertis-ing and marketing strategies may offer packagespecials, yet you do not need to competitively offerendless promotional discounts.

MARKETING ANDADVERTISING STRATEGIES

Do you want to become known as the top derma-tologist or the top medical spa in town? If you wantto become respected as the best team of aesthe-ticians and medical spa professionals in your area,you need to create a complete annual marketing,advertising, and PR strategy dedicated to provid-ing high-quality state-of-the-art medical spaservice treatments, while balancing these with

your other services. If no one has created a posi-tion for themselves as the leading medical spa intown, then you need to create a marketing planthat will earn this title for you. Even if plenty ofothers offer aesthetic, medical, and spa serviceslocally, you can become respected as the topmedical spa. There are many options and promo-tional strategies that you may consider.

ADVERTISING BUDGETS

We suggest that you project an investment towardyour annual marketing, advertising, and PR budgetof at least 5% to 8% per year. A 3% budget ismuch too lean, whereas a healthy and aggressivebudget would be 10% to 12%. Each year youshould project your annual sales for the next yearso that you may project your annual marketinginvestments; these can easily be adjusted ona quarterly basis as needed. This annual projectionis important, so that you can be prepared for theslower and the more successful months eachyear. A new medical spa should project no lessthan 10% to 15% for the first 2 years.

PRINTADVERTISING

Print advertising is essential for you and yourmedical spa. Despite the advent of the Internet,most Americans are still visually oriented, seekingnews and information from the print and broadcastmedia. That is why USA Today, People magazine,and CNN Headline News are so popular. Everythingyou print must be professional, well designed, col-orful, and have terrific photographic illustrations.

Advertising Campaigns

Work with a professional graphic designer, writer,or a marketing agency to develop a complete,comprehensive and consistent advertising cam-paign. To build name brand awareness, youcannot randomly allow the advertising media toindependently create your advertising for youone advertisement at a time.

Advertorials

Explore advertorials; these should look like edito-rials, yet they are paid advertising space. Anadvertorial appears to be an editorial article, butin the small print you are required to use theword ‘‘advertisement.’’ They can look like anyother feature article in that same newspaper ormagazine. You can pursue advertorials in yourlocal newspapers and regional magazines or pur-chase them on a regional basis in major nationalmagazines, such as Town & Country, People,Glamour, Self, and Allure.


City and Regional Magazines

Consider advertising your medical spa services,makeovers, and aesthetic artistry in some of thebest local city and regional magazines. This adver-tising is one of your most effective marketing strat-egies, especially when combined with direct mail.Even if you only acquire one third, one half, or full-page advertisements three to six times per year,this helps to position you as one of the top medicalspas in town. The regional magazines are usuallywell respected by the most affluent executives,homemakers, politicians, and trendsetters in yourarea. You should definitely be in every Best Of,To Doctors, Health Care, Medical, and MedicalSpa theme issues you can work with. Try to re-quest right-hand page positions within the firstthird of the magazine. You can negotiate for annualagreements to save money. Market research hasshown that the most read and preferred advertise-ments have a right-hand page position within thefirst third of the magazine, so positioning your ad-vertisement appropriately may help to yield higherreturns on your investment.

Community and MetropolitanNewspapers/Magazines

We do not recommend advertising in regularnewspapers unless they are offering a specialMedical, Spa, Wellness, or Best Of section. Ifthey have their own Sunday magazine insert inthe large metropolitan editions, you should con-sider a long-term advertising agreement here.

In most large metropolitan communities todaythere are special magazine-format vehicles thatcater to medical, health, and wellness profes-sionals. Some of these offer the options of adver-tising, advertorials, and editorials, so be sure toexplore every potential option.

Research the various media opportunities avail-able to you. Write down their contact information(Table 2) and invite the advertising sales represen-tatives to come in for a presentation.

Table 2Media opportunities

Media Contact Name

Local community newspapers

College/student newspapers

Regional city newspapers

Metropolitan city newspapers

Regional magazines

Other print media options

Direct Mail Marketing

Direct mail can be facilitated independently, withdirect mail houses and through local printers andnationally recognized direct mail resources thatare available in most major communities acrossAmerica. Direct mail should become an essentialpart of your annual medical spa marketing strat-egy. Look at various direct mail marketing and ad-vertising opportunities available to you (Table 3).Visit your local Yellow Pages or explore the Inter-net to find direct mail resources near you.

Collect the names, addresses, telephone num-bers, and E-mail addresses from your patients.Create a computerized direct mail database ofyour patients so you can mail them special post-cards, newsletters, fliers, and brochures. Youcan send customized postcards or E-cards toyour database of patients wishing them happybirthday, as reminder cards for their upcoming ap-pointments if scheduled far in advance, or evena ‘‘We Miss You’’ greeting (eg, ‘‘We haven’t seenyou in 6 months and we’d like to offer you a newservice!’’). Often the highest yield for return onadvertising investment is based on retaining cur-rent patients for repeat business. It costs far lessin advertising dollar return on investment to retainexisting patients than it does to acquire new ones.

To advertise to potential new patients, localdirect mail houses can sell or rent you lists of tar-geted homeowners and businesses near yourmedical spa. Often they can help write, design,produce, print, and mail these for you. They canmerge your own database with targeted homeswithin a 3 to 10 mile radius of your medical spa.For a slightly higher price, they can help you targetcertain streets, incomes, and demographicchoices, rather than just blanket the entire tar-geted zip code.

With more than 99% of American homes nowturning to direct mail and coupons as part of theireveryday pattern for shopping and to find re-sources near their homes, many medical practiceshave also turned to direct mail as a viable source

Telephone Number E-mail Address

Table 3Direct mail options

DirectMail Resources Contact Name Telephone Number E-mail Address

Solo direct mail

Newsletters

Postcards

Clipper/Savvy Shopper/MintMagazine

ValPak/Money Mailer

Free-standing inserts

Detached address label cards

Other options

Sadick et al396

for creatively increasing their revenue. This adver-tising and marketing format is quickly becomingmore favorable with medical professionals.

Newsletters and E-mail Newsletters

We suggest you write and facilitate a professionalnewsletter for your regular patients and targetedhomes in your community two to six times peryear. These newsletters become an effectivemarketing tool if you use them to educate your cur-rent and prospective patients about the benefits ofyour varied services and specialties. Most peopledo not know what goes on behind closed doors.The fear factor keeps most people from askingabout services or their costs. We strongly suggestthat you do not make these overtly commercial.Most newsletters should go from a single sheet ofdouble-sided and printed paper to four 8.5� 11-inpage formats, with a full-color layout usingphotographs.

You should talk about your staff, specialties,seasonal procedure updates, seminars, and spe-cial events. You should also tell folks if you haverecently been published or in the news. Directthem to your Web site. Show photographs ofyour staff, facilities, and makeovers. There is noneed to offer specials or discounts. Keep newslet-ters informative, so the recipients look forward toreceiving them.

Should you develop an ongoing program,research using bulk mail indicia at your local postoffice. These newsletters can also be facilitatedby E-mail if they are kept to one page. They canalso be distributed as free-standing inserts withinyour local community newspapers, often muchcheaper than by mail.

If you do not have a professional writer ormarketing associate on staff, hire an outsideresource so that your presentation is extremelyprofessional.

An E-mail marketing campaign should becomeanother essential part of your annual medical spamarketing strategy. You can create colorfulE-mail blasts with some of your most importantnews, special event announcements, and make-overs. Create a special computerized E-mail data-base of your patients so you or your Webmastercan E-mail them on a regular basis.

Solo Direct Mail

At approximately 3 to 4 cents per home, direct mailmagazine or cooperative format marketing isextremely affordable, as opposed to solo directmail campaigns, which usually cost between50 cents to 1 dollar or more per home. Solo directmail is also extremely effective, however. You canindependently facilitate newsletters, postcards,full-sheet fliers, letters, brochures, and marketingdevices. For solo direct mail, you need to writethe copy, create the artwork, determine your tar-geted markets, and hire a local direct mail houseto facilitate the mailing.

Postcard Campaigns

Postcards are useful as reminders for next ap-pointments, to promote new staff, announce newservices, thank patients for their first visits, thankthem for referrals, and much more. Each patientshould receive a personalized thank you postcardafter every visit, while seasonally promoting somepotential new service or treatment option for them.Create colorful postcards with beautiful skin care,body, and makeover photographs and your logoon the front with a personalized message aboutcomplimentary consultations on the reverse side.

Upscale Direct Mail Magazines

With direct mail magazine formats, you can specif-ically target neighborhood homes surrounding


your medical spa practice. Explore upscale Clip-per Magazine, Savvy Shopper, and Mint directmail magazines, in which you can affordablypromote your services for less than 3 to 4 centsper home while reaching 50,000 homes surround-ing your medical spa per targeted mailing area.Priority position within these direct mail magazinesmay be a factor for you. If available, explore buyingthe front or the back covers and the first fewpages.

Explore every possible option with each vendor.For example, the Clipper Company offers manyother special marketing devices. Some are tar-geted specifically to new homeowners, and theycan also host and facilitate your E-mail loyaltyprograms on a monthly basis with E-mails sentto your E-mail database.

Clipper Magazine, Savvy Shopper, and MintMagazine sales representatives are prepared tohelp you plan the most effective annual directmail marketing campaigns with customized adver-tising solutions for your business. For example,Clipper Magazine is a unique premier-quality full-color glossy direct mail magazine. Because ofour success here, we have begun to work withthem directly for many of our clients. For a compli-mentary direct mail consultation or more informa-tion about Clipper Magazine, Savvy Shopper, orMint Magazine call 866-802-1429, E-mail [email protected], or visit theirWeb site at www.ClipperMagazine.com. Clipper,Savvy Shopper, and Mint Magazine are known assome of the best premier-quality full-color directmail advertising magazine publications in theUnited States.

Cooperative Direct Mail Envelopes

A few examples of some of the best direct mailcoupon envelope resources, such as Valpakand Money Mailer, cooperatively mail loose inde-pendent coupons from various local servicebusinesses, medical professionals, and retail busi-nesses to 10,000 homes per targeted zone (www.valpak.com or www.moneymailer.com).

When you add up the costs of artwork, printing,mailing labels, and postage, it is a greater

Table 4Marketing program organizer

Newspaper advertisements

Magazine advertisements

Counter cards

Post cards

Other options

advantage to use colorful and upscale direct mailmagazines, cooperative direct mail, or a combina-tion of both, whether or not you also use solo di-rect mail campaigns.

Detached Address Labels/Postcards

These are the special full-color oversized postcard-style devices that ride along with free-standinginserts within your city and metropolitan newspa-pers. You can purchase these through Clipper,Savvy Shopper, and Mint Magazine at approxi-mately 9 cents per targeted home.

Free-Standing Inserts

These are the special inserts that are distributedwithin your city and metropolitan newspapers,with broadsheets and marketing materials fromdrug stores, supermarkets, home improvementbusinesses, and other local merchants. Your med-ical spa newsletters can be distributed by way offree-standing inserts more affordably than bypostal mail.

Boilerplate Medical Spa Marketing Programs

Some manufacturers and vendors offer profes-sionally predesigned brochures, posters,postcards, and newspaper and magazine adver-tisements to which you can easily add your ownmedical spa logo, address, telephone number,and Web site information. These are fine, yet ifpossible you should create your own uniqueidentity with a complete, consistent, and ongoingmarketing program (Table 4).

Aesthetic, Cosmetic Surgery, and MakeoverConsultation Books

Create your own personalized makeover consulta-tion and presentation books. These are excellentmarketing tools that help turn a preliminary consul-tation into a confirmed appointment. They areimportant visual presentations of your medicalspa. Share as many of your own makeover photo-graphs as you can in your advertising, posters, andpoint-of-purchase materials.



http://www.ClipperMagazine.com





http://www.valpak.com

http://www.moneymailer.com

Sadick et al398

New Patient Kits

Create a special folder with your logo on it for first-time patients, facilitating a formal presentationwith your brochures, media kit pages, backgroundon your doctors and staff, and notes on potentialpayment options. These should be personallypresented in a private consultation.

Medical Spa Photography Sessions

We strongly suggest that you hire a photographerto take pictures of your staff, building, facilities,and services; this is much better than using stockphotography. Although stock photography is inex-pensive, you run the risk of having every othermedical spa, salon, and skin care clinic in townusing the same photographs you purchase. Ifyou do want to explore stock photography, visitwww.istockphotography.com.

Many cosmetic surgery centers and medicalspas have a camera on hand, and some evenhave a permanent photography studio room setup to record every patient makeover. You canask some of your patients to sign model releasesso you can use their makeovers in marketing,advertising, and PR.

Promotional Strategies

You may want to offer a $100 or $200 gift certifi-cate discount toward any first-time medical spaservice. You can offer a free gift with purchaseby offering a large gift of professional productswith the purchase of any large medical or aestheticservice package.

Point-of-Purchase Merchandising

Be sure to design or acquire and place patient bro-chures, counter cards, and PR reprints throughoutyour medical spa. You may use the merchandisingdevices supplied by vendors and manufacturers,but it is best to create your own tasteful, colorfultent cards, counter cards, shelf talkers, posters,and outdoor signage that seasonally promotes allof your medical spa services. Be sure to sharelarge photographs of your best aesthetic, spa,

Table 5Radio and television advertising options

Media Contact Name

Local cable television __________________

Network television __________________

Regional radio __________________

Other options __________________

massage, and medical service makeovers onwomen, men, and teens.

Web Site Marketing

You need an effective Web site. Make sure yourWeb site promotes your medical spa services,sharing a complete gallery of your own makeoverphotographs. Share news about your doctors,aestheticians, staff, services, media honors, andspecial events. Take the time to do an Internetsearch of other medical spa Web sites acrossthe United States to get some ideas. You canalso explore banner advertisements or paid Inter-net and Google Search Ad Words. Hire a profes-sional Web designer and Webmaster to give yourWeb site a professional look with superb graphicdesign that incorporates your logo and brandingimages, hoisting and updating it on a regular basis.

Radio and Television BroadcastAdvertising Options

Radio and television are terrific. Cable televisionaffordably offers you the opportunity to visuallypresent your medical spa, services, makeovers,and benefits. Radio is a bit less advantageousbecause it is really theater of the mind, so youmust be able to paint word pictures. We thereforeonly recommend cable television and radio adver-tising in small city markets or if you have multiplelocations in a large metropolitan city.

Network television on ABC, CBS, FOX, and NBCmay be affordable in smaller markets, so it is worthexploring if you can afford to buy advertisingduring prime time news or surrounding some ofthe latest medical, makeover, and wellness realityshows.

Radio and television media are usually expen-sive if you buy preferred drive-time spots. It isnot worth buying ‘‘run of schedule’’ with odd hoursin the middle of the night. Radio and televisionusually target a much larger area than you need;most medical spa patients will only drive 3 to5 miles for their services. If you can afford it andyou can put together an ongoing campaign, thendo it (Table 5). Your radio and television stations

Telephone Numbers E-mail Address

__________________ _______________

__________________ _______________

__________________ _______________

__________________ _______________

http://www.istockphotography.com


will help you create the commercials, so negotiatefor these as part of your annual advertising agree-ment package. Target your television or radiocommercials to your target market by factorssuch as age, gender, income bracket, ethnicity,and marital status by choosing specific time slotsor television shows that are viewed by yourdesired target market. Your local television orradio advertising sales staff can help you narrowdown this strategic process.

Some local radio, cable, and network televisionstations are able to offer you the option of infomer-cials; you can create and produce your own 30 to60 minute television shows in their studios or atyour own medical spa facility.

Yellow Pages

We are not big fans of printed Yellow Page directo-ries or any local telephone directory because mostpeople today do not let their fingers do the walk-ing. We only recommend small free listings orsmall display advertisements, rather than the largefull-color display advertisements. If you do desireYellow Page presentations, be sure to explore allof the various categories for skin care clinics, med-ical spas, dermatologists, and more. There aresome valuable Internet directories and Web-basedYellow Page directories that are worth exploring.

OTHER ADVERTISING ANDMEDIA OPTIONS

The signage on your building or at your office isone of the most important and powerful invest-ments you can make. Make sure you have anattractive logo with a well-designed and well-litsign.

You can explore billboards, bus cards, bus shel-ters, signs at sports stadiums, advertisements inupscale neighborhood telephone directories, andads in area church, temple, and religious newslet-ters; the list of potential advertising options seemsto go on endlessly. It is smart to explore some ofthese creative new ideas, yet you do not need tobe everywhere. Instead, selectively pick the bestoptions that work for you with a consistent andcomprehensive campaign to reach your targetmarket.

ADVERTISING TIPS

Present a strong image. Remember that today’sconsumers are visually oriented. People tend toread advertisements with colorful photographsand logos that are supported by strong headlineswith clear messages. It is good to be clever, yetwhen you get so cute that readers do not easilyknow what you are selling, they may completely

miss your message. You must be able to stopcustomers in their tracks with strong visualpresentations.

Use Quality Photographs, Logos,and Colorful Illustrations

For added effectiveness, try to maintain a consis-tent visual image for your medical spa throughoutall of your advertising, direct mail, and marketingcampaigns. If you have any photographs, usethem. Customers will read all of the small detailsonce they are attracted by your consistently beau-tiful photographs, logos, colors, and headlines.

Use Full Color

A picture is still worth a thousand words. Whenpossible, avoid most black and white marketingoptions. Look for professional full-color printingcapabilities. You can affordably market yourservices and products in full color to ensure thebest possible redemption. Research has shownthat full-color advertising options can increaseredemption rates by 30% to 60%.

‘‘Free’’ Always Works Great

Nothing beats ‘‘free’’ or ‘‘complimentary’’; theseterms can help persuade your current regulars totry new services or products and get new patientsto try you for the first time. Consider offering a freeconsultation or a free product gift with a specialseries service package. You can make an offer,such as ‘‘Buy Any Six Series Service Treatmentsand Get the Seventh Free,’’ to promote ongoingfacial treatments, body wraps, and massagetherapies.

Use Dollars Off, not Percentages

If you elect to offer specials on some of your spaand aesthetic services, patients react much betterto strong dollars-off discounts and incentives. Per-centage discounts are not perceived to be asstrong, especially if they are only 10% to 20%off. Unless you use 50% off or higher percentagediscounts, they are perceived as weak offers andignored. For example, try: ‘‘$20 Off—$100 ValueServices and Up’’ or ‘‘$10 Off Any Two MedicalSpa Products—Minimum $50 Value.’’

Use Care with Disclaimers

Try to avoid excessive disclaimers and rules forwhat is not included in direct mail and advertisedspecial offers. Try to keep your special offerssimple with words like, ‘‘No Double Discounts.Expires 00/00/09.’’ Use expiration dates of nomore than 60 to 90 days to keep your offers timely.

Sadick et al400

Always Introduce New Services,Products, or Equipment

Special new spa services, aesthetic products, andequipment can be featured seasonally within thesame advertisements. Although it is best to pro-mote your strongest and most popular services,it is still important to promote the special benefitsof the unique services, merchandise, and equip-ment that people might not know you offer. Mostconsumers prefer convenience and one-stopshopping alternatives, so if you offer somethingextra special, unique, or distinctively different,take advantage of the opportunity to promotethat. Once they trust you, most patients are happyto use several different types of services.

SEASONAL PROMOTIONS

Unlike traditional medical clinics, you can promotegift certificates for some of your aesthetic and spaservices. You can create promotions for Valentine’sDay, Mother’s Day, Father’s Day, graduations, andthe year-end holidays. You can promote Spa SeriesSpecials, Gifts of Beauty, and Spa Packages. Giftcertificates have become the best way to havea paid new patient referral program. You may wantto facilitate some cross-marketing programs withother professional noncompeting service providers.

TARGETED PROMOTIONAL STRATEGIES

You can create and market directly to teens, men,women who have cellulite challenges, or whomeveryou wish. It is wise to create an annual marketingcalendar, with mostpromotions targeted to your de-sired audience. It is also important to have at leastsome promotions targeted to other markets. For ex-ample, men make up 38% of all spa visitors for skincare, massage, and body treatments. Teens, col-legestudents,andyoung careerwomenare becom-ing an ever-increasing market. If you are focused ononly targeting upscale women aged 30 to 55, youare missing some of your potential marketplace.

JOINMEDICAL ANDMEDICAL SPA ASSOCIATIONSANDATTEND CONVENTIONS

You can join the International Medical Spa Associ-ation, the Day Spa Association, the InternationalSpa Association, and many other fine organiza-tions that host special events, lecture seminars,and conventions. You should attend as manymedical spa marketing, advertising, and PR semi-nars as possible or get someone on your staff tohelp stay up on the latest trends. Examples canbe found at www.MedicalSpaAssociation.organd www.DaySpaAssociation.com.

PUBLIC RELATIONS ANDMEDIARELATIONS STRATEGIES

You must pursue local and national PR exposureto promote your medical spa services and staffand to educate the public on your specialty ser-vices. Public and media relations are not paidmedia exposure and thus they must be handleddifferently from paid advertising strategies.

You cannot over-commercialize or sell anythingthrough PR by way of press releases and featurestories. Media relations are a specialty. It is notpaid advertising, so it must be handled profession-ally. Plan a medical spa and makeover photogra-phy session so you can share your best servicesand work with the local newspapers and thenational trade magazines. The more PR exposureyou get, the more PR you will get. Once published,it is important to create a ‘‘Wall of Fame’’ for yourmedical spa. These special media honors shouldalso be used in your newspaper advertisements,postcards, newsletters, and on your Web site.

Develop a professionally written and printedmedia kit with biographies on your medical spadoctors and aestheticians. Create a series of pressreleases. Research editorial calendars of the localmedia so you can send out cover pitch letters withmedia kits at least 4 months before they plan tofeature top doctors, top spas, top medical spas,or to publish a Best of City issue. Not only is ita great honor to be published but these mediaaccolades bring you plenty of credibility, respect,pride, and new patients.

Develop your own local, regional, and nationaltarget media lists with the names, addresses,E-mail addresses, and telephone numbers ofyour preferred media targets. Although it is impor-tant to pursue local media, you will be wellpositioned if you can also start a national PR cam-paign. Local media prefer to work with nationallyrecognized experts, rather than just any localdoctor or aesthetician. Developing a series ofnational and international media honors while writ-ing some feature stories for nationally respectedtrade publications is definitely in your best interest.Once published nationally, share PR reprints withyour local media by offering to share your exper-tise with a regular newspaper column, in a featurestory, or on a special television news or talk show.

PR should be handled by a professional thirdparty, so find someone locally or hire a respectedindustry professional who understands medicalspas. Remember that PR is not a paid medium,so your PR pitches must remain educationallyoriented and totally noncommercial.

If an editor ever gets anything wrong, be carefulnot to complain. You may never get any press

http://www.MedicalSpaAssociation.org

http://www.DaySpaAssociation.com


again from that writer or editor if you complain.There are only two rules in PR. Rule #1: The editoris always right. Rule #2: If the editor is ever wrong,reread rule #1. The best local media resources allknow each other and they move around, so it isbest to establish positive long-lasting relation-ships. Do not be afraid to invite in medicallyfocused newspaper writers, magazine editors,and television producers for a complimentaryconsultation and introductory service, so theymay have a personalized tour of your facility.

SPECIAL EVENTS

Open houses and lecture demonstrations arewonderful to lure in prospective new patients,while also cross-marketing some of your regularsinto more services. Create and promote a seriesof lecture demonstrations at your own facility andat Chamber of Commerce luncheons, special net-working events, and community fairs.

CHARITY EVENTS

You may be able to promote your medical spaservices by being affiliated with a charity. Annual-ized events to benefit skin cancer, breast cancer,prostate cancer, leukemia, and special children’scauses, such as cleft palate, a local women’s shel-ter, Locks of Love, or any favorite charity are worth-while. As a medical spa facility it is wise to work witha charity that is related to skin care and health carechallenges. Take the time to visit with several tar-geted charities to see how you can work togetherbefore the event to maximize pre-event publicity.

Donate gift certificates to help local communityevents and charitable fundraisers, to promoteyour facial treatments, massage therapies, andthe more traditional spa services. This donationhelps get your name out in the community.

STAFF RECRUITMENT MARKETING

All of our advertising, marketing, and PR cam-paigns could and should draw potential new med-ical, aesthetic, and staff professionals. You shouldalso create a special brochure for prospective staffand employees. Your Web site should have onepage dedicated to promoting career opportunities.

CREATE NEWMEDICAL SPAMARKETING SOLUTIONS

There is a huge and growing market today forprofessional medical spa services. Take advan-tage of this open marketplace by creating a com-plete marketing, advertising, and PR program to

promote yourself, your staff, and your medicalspa. If you expect to merely open your doorswith a great staff, wonderful equipment, and bigdreams, you will be sadly waiting for the customerbus to arrive each day. As the owner of a medicalspa, you need to wear many hats. You must alsoplan to put on the bus driver’s hat with a completemarketing, advertising, and PR program that willdrive new patients into your medical spa.

You can certainly do it all yourself, although wedo not recommend it. It is best to hire a full-timestaff marketing associate or to hire a professionaloutside resource. If you do hire someone inter-nally, be sure they are capable of giving you a com-plete marketing, advertising, PR, and graphicdesign service while you give them all of the bud-gets and tools to succeed.

If you hire an external resource, you can searchfor resources within your own community. You donot need to hire someone locally, however. It isbest to find and individual or a full-service agencythat understands medical spas, skin care, and der-matology, so you do not have to train them in howto market your service specialties. You can hirea publicist, while also separately hiring a graphicdesigner for you and an assistant to supervise.We believe it is best to put all of this responsibilityunder one person or one roof, so your marketingcampaigns are consistent, well integrated, andeffective. With the Internet and telephone, yourmarketing, advertising, and PR agency can belocated anywhere.

In our experience successfully working withinthis specialized industry for more than 30 years,once your medical spa begins to thrive it is moreeffective to hire an outside agency that specializesin medical spa, wellness, and beauty care market-ing services. If you have enough resources, yourcompany will grow faster if you can hire a profes-sional agency from the beginning, when you firstlaunch your new medical spa business. In thatway you can serve your patients best by beinga specialist in medical spa services and you canrefer your marketing needs to a specialist in thatfield. You can make money doing what you loveand someone else can design and execute yourcomprehensive marketing strategy.

MARKET-DRIVENMEDICAL SPA STRATEGIES

We professionally recommend that you make thechoice to successfully and competitively becomea market-driven medical spa with an annual strate-gic plan, rather than to become an operationallydriven business. The choice is yours.

Spa Dermatology: Past,Present, and Future
Joel Schlessinger, MD, FAAD, FAACS
KEYWORDS� Spa � Medispa � Spa dermatology � Medical spa� Day spa

Spas have been identified back to times of theancient Babylonians and Greeks. The Romansare responsible for instituting the spread of spasover much of the world as their empire spread.1

The trend toward relaxation and reward for over-worked people seems to be increasing and hasdeveloped a more clinical and medical flavor inthe 21st century. This article details the past, pres-ent, and future of spa dermatology and discussesthe implications for dermatologists.

m

HISTORYOF SPAS

To understand and fully appreciate the place andpotential of medical (particularly dermatologic)spas, it is important to recognize the history ofspas. The word ‘‘spa’’originates from the Latinverb ‘‘spagere’’ to pour forth. As practiced by theMesopotamians, Minoans, Greeks, Romans, andother ancient cultures, the spa experience in thosetimes may truly have been curative, especiallygiven the lack of bathing by the general populacein those times and the benefits that regular orsemiregular bathing most likely afforded.2

According to SpaFinder:2

Homer and other Classical writers report thatthe Greeks indulged in a variety of social bathsas early as 500 BC, including hot air bathsknown as laconica. In 25 BC, Emperor Agrippadesigned and created the first Roman ‘‘ther-mae’’ (a large-scale spa), and each subse-quent emperor outdid his predecessor increating ever-more extravagant thermae.Over time, they were built across the RomanEmpire, from Africa to England, graduallyevolving into full-blown entertainmentcomplexes offering sports, restaurants, and

Advanced Skin Research Center, 2802 Oakview Mall DrivE-mail address: [email protected]


various types of baths. A typical routine mayhave involved a workout in the palestra, fol-lowed by a visit to three progressively warmerrooms, where the body was alternatelybathed, anointed with oils, massaged andexfoliated. The ritual would end with a bracingdip in the ‘‘frigidarium’’ followed by somerelaxation in the library or assembly room.

We may think of today’s spas as elaborate, butthey pale when compared with these ancientreports. Spas were a significant form of entertain-ment in that period, and that may account for theirsplendor. There is no doubt that that these spaswere valuable medically and antiseptically.

Different traditions involving spas have evolvedin various areas of the world, often coincidingwith religious traditions and natural springs pres-ent in the area. For example, Japan started its first‘‘onsen’’ spa near Izomo in 737 AD, which led toinns named ‘‘ryoko’’ scattered about the country.These, in many instances, contained Zen gardens,outdoor baths, and soaking tubs. Japan, beinga volcanic island, has at least 150 hot springswith 14,000 individual springs, and these playeda significant role in spa culture and developmentthere. Two types of springs are found. Virgin watersprings occur where the earth’s magma coolsdown and is released as a mixture of vapor andgases, which turn into water. Fossil liquid springsoccur when ancient forms are dissolved and returnto the surface via these springs thousands of yearslater. Springs may be classified by their contentand temperature, leading to classifications ofsprings as simple, carbonate, heavy carbon soil,salt, saltine sodium hydrogen carbonate, mirabi-lite, mirabilite sodium chloride, gypsum, true bitter,iron, acidic, alum, sulfur, and radium. Each of

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these types of springs has been identified as hav-ing various medicinal and healing properties.

Japanese authorities recommend not washingoff for at least 6 to 7 hours after exiting the springas the minerals take that time to fully ‘‘absorb.’’Many authorities recommend drinking the water(if it is safe) to maintain full benefits.3

In Finland there is one spa per each two Finnishinhabitants, with equal representation of thesespas for women and men. Towns such as Spa,Belgium; Baden-Baden, Germany; and Bath,England centered around natural springs and pro-moted the visibility and overall awareness of spas.

Early in 1350, many spas were destroyed due tothe bubonic plague and the thought that they mayhave been responsible for its spread. In 1538,France razed its public baths due to the thoughtthat they had contributed to an ongoing epidemicof syphilis. These examples are in contradistinc-tion to events in the 19th century, when it becamethe vogue to travel to spas for the treatmentof syphilis and other sexually transmitted dis-eases. In respect to these examples, Thomas M.Lachocki, Ph.D., chairman of the National Spa &Pool Institute’s Chemical, Treatment and ProcessCommittee and director of product developmentat BioLab Inc. in Decatur, Geaogia, notes ‘‘Thelikelihood of transmission is very, very, very, very,very low. Anything could happen, but it’s extraor-dinarily unlikely.’’ An important layer of protectionshields hot tub users against sexually transmitteddiseases, according to Lachocki, in that the wateris treated with chemicals that are designed to killviruses and bacteria.

Lachocki says, ‘‘When you look back at some ofthe literature in the late 1800s or early 1900s, peo-ple would often travel long distances to differenthot springs and spas to treat syphilis.’’4

The United States started its first spas in the1850s in Saratoga Springs, New York. Innovationsand elaborations followed with the opening of theRed Door Salon in Manhattan in 1910 and theadvent of other icons such as Tucson’s CanyonRanch in Arizona, Rancho La Puerta in Baja, Cali-fornia, and the Golden Door in California. Thesespas generally catered to famous clients, such asPresident Franklin Delano Roosevelt and JaneFonda, many of whom extolled the virtues of thistype of activity and promoted the development ofspas in the United States.

Medical spas became a part of the picture in themid-1990s, with dermatologists among the firstoperators. Dr. Michael Gold (Nashville, TN) wasmost likely the first dermatologist to open a medi-cal spa in 1991, followed by Dr. Barry Ginsburg(Birmingham, AL) in 1995, this author andDr. Mitchell Goldman (La Jolla, CA) in 1996

(Dr. Mitchell Goldman, personal communication,2007), and Dr. Bruce Katz (New York, NY) in1999, who coined the term MediSpa.5 All thesedermatology-based facilities shared the goal of in-tegrating medical and spa-like atmospheres in thesame building.

According to Dr. Gold (Michael Gold, MD,personal communication, 2007):

We opened up our spa and spa services in1991 and it was unchartered territory in der-matology. The response from the communitywas very positive and we have continued tooffer products and services over these past16 years. When we first opened, I was ner-vous that I was bucking a trend in dermatol-ogy but I truly believed it fit a need that wasnot being performed in our field. And despitea lot of early criticism, the spa conceptis pretty much standard in our business intoday’s world.

Dr. Ginsburg describes his opening of his spa asfollows (Barry Ginsburg, MD, personal communi-cation, 2007):

We first opened our ‘spa’ which was really anacne clinic in the early 1980’s. I am not awareof any other similar clinics in doctors’ offices,but there may have been a few. We didn’t callit a spa back then. It operated out of one roomin my office and was called Skin Dynamics.We mainly did acne facials and light chemicalpeels. We realized that we wanted to do morefor our acne patients. Medical treatmentalone didn’t seem to fulfill all the acne pa-tient’s needs. I guess you can say we openedour clinic to offer a wider range of options foracne patients in a more relaxing environmentwith an RN who did treatments. We alsoselected a line of cleansers and cosmeticsthat we liked for acne. At that time acnemake ups were not very elegant and thedepartment store options were confusingand inadequate. We expanded the servicesas we saw the need for anti-aging treatments.At first I did TCA peels and soon glycolic acidbecame popular and we started doing gly-colic acid peels, and started selling homeproducts for anti-aging. This was before anytopical antioxidants were used. We mainlyrelied on retinoic acid (which was not yet ap-proved for anti-aging) and glycolic acid prod-ucts. When I moved my office in 1992 weenlarged the area, adding several treatmentrooms and a private waiting area. We still spe-cialized primarily in acne and anti-aging treat-ments. Soon, IPL and laser hair removal came

Spa Dermatology: Past, Present, and Future 405

into being and we began to perform thosetreatments in the SPA area. In 1995, I openeda free standing, very eloquent, day spa inMountain Brook Village. This was more ofthe relaxing kind of spa. We offered mas-sages, facials and a full line of beauty prod-ucts as well as anti-aging products. Weclosed this spa after about 5 years becauseof the enormous amount of work it requiredand the relatively high overhead/low profit-ability. I now have a smaller spa in my officewhere we sell cosmetics, cosmeceuticals.Additionally, we offer IPL, Sciton light laserpeels, laser hair removal, facials and mas-sage. It is onsite and I supervise all lasertreatments.

My employees have all been there morethan 5 years and it basically runs itself. It canbe a very high maintenance area and I wouldnot recommend it for someone who is justlooking for some easy money, because it isn’t.

I think there is a limited future for spas. Asmore states pass supervision laws, it will bedifficult for unsupervised spas to operate. Itseems there is a spa popping up on everycorner now, so the competition is severe. Ifthe physician owns a spa he will have to relyon someone to manage it, and thoseemployees tend to jump around from spato spa.

In the beginning, most of these medical spaswere inside the practice and moved from havingan esthetician who visited or worked for the prac-tice to a stand-alone esthetician to a stand-aloneor ‘‘practice-within-a-practice’’ spa.

The author’s experience with the medical spabegan in 1995, 2 years after I started practice,when a patient of mine who was an estheticianasked to work for me in some capacity. She wasexcited about the opportunity to work in a derma-tology practice because she had been trained inparamedical aesthetics. At the time, my practice’slimiting factor was space because I operated ina facility that contained only about 2600 squarefeet total space. My esthetician was hired withthe understanding that she would probably notbe busy from the outset but would grow with mar-keting and promotions from within the practice. Atfirst, she performed tasks ranging from filing tofront desk work when she was not busy withesthetitician activities. The room that she usedwas our former break room. Sadly, no other breakroom space existed except for the previous bath-room, which became our ‘‘break room.’’ Luckily,we had another bathroom down the hall, whichbarely sufficed until we built space for the spa.

In 1996, we built out a space for a spa in thebuilding next to that which housed our dermatol-ogy practice. It was a small, 1500-square footfacility that had three treatment rooms and onebreak area. Two of the rooms were for an estheti-cian, and the other was eventually used for laserhair removal treatments and endermology treat-ments. There was adequate space for productdisplays, and it served well, but there was a prob-lem in that many patients who were recommen-ded to go to the spa to speak with anesthetician did not make it the 50 ft from the prac-tice to the spa next door. The situation promptedus to look into other space, where the spa and themedical practice could co-exist. This space wascreated over the next 2 years in a facility thathoused all of our activities. The spa (Aesthetica)emerged with improved functionality, and the inte-gration of the estheticians (by this time three) intothe rest of the practice achieved the expectedsynergism.

During the intervening years, the spa has func-tioned quite well, but its focus has been moremedical than pampering in nature. Although thespa has massages and facials as options, theseare not the bread and butter of the spa and neverwill be. Additionally, manicures and pedicures arenot popular because our prices are more than thestandard salons in town. Some procedures, suchas waxing and lash tints, are routinely performedin our spa with good results at fairly comparableprices, but these are not heavily promoted. Otherprocedures, such as endermology and microder-mabrasions, are popular and have been mainstaysduring the entire time in the old and new facility.For these procedures, patients may benefit frombeing seen in a dermatology practice first andthen bringing these problems from the initial orfollow-up consultation to spa visits.

Having an integrated spa within a medical prac-tice has been of benefit and has allowed for theclose interplay between the estheticians andmyself. During the past 12 years, I have workedat teaching my estheticians about dermatologyduring their employment, and I view them ashelpers for the practice and as teachers forpatients about products and procedures. Theirlicenses allow them to do certain things that I can-not do and vice versa.

The lines of delineation of activities in my prac-tice have been somewhat changed over time,based on state regulations and the determinationof which procedures can and cannot be best per-formed by estheticians. What this author findsmost rewarding is the ability to offer his patientsa truly different experience that would not be avail-able in a traditional dermatology practice.

Schlessinger406

PRESENT SPA DERMATOLOGY

Spa dermatology has grown to a $1.063 billionbusiness. According to the International Spa Asso-ciation, medical spa revenues doubled in 2007 ascompared with 2006. Out of a total of 14,615 spasin the United States, only 976 were ‘‘medical spas’’(7% of the total), but these medical spas provideabout 12% of the income for the entire spa indus-try. Other salient features presented by this report:

� There were an estimated 14,615 spas in theUnited States in August 2007, up 6% from13,757 spas in August of 2006 and contrastedwith 10,128 spas in April of 2004.� Despite the growth of spas, the rate of growth is

slowing.� The number of day spas, resort/hotel spas,

medical spas, and destination spas increasedbetween 2006 and 2007. The number of clubspas and mineral-springs spas decreased.� There are 11,736 day spas in the United States

80% of the total number of spas. There are1345 resort and hotel spas, comprising 9% ofthe total. The medical spas number 976, whichis 7% of the total. There are 428 club spas,which is 3% of the total, and 51 mineral springsspas represent 0.4% of the total.� There are 79 destination spas, comprising

0.5% of the total.� Although there were more spas in the United

States, revenues fell 3.4% from $9.7 billion in2005 to $9.4 billion in 2006. Revenues at medicalspas more than doubled during the same period.� Revenues for the day spas were $5.294 billion

in 2006, down from $6.794 billion in 2005.Resort and hotel spas had revenues of$2.499 billion, up from $2.026 billion, and med-ical spas showed income of $1,063 billion, upfrom $469 million in 2006. The income at clubspas was $242 million, up from $209 million.� Visits to spas totaled 110 million in 2006, a 16%

decline from the 131 million spa visits in 2005.The number of spa employees also declined,perhaps reflecting the emphasis on medicalrather than other types of spas, with increasedefficiencies. There were 234,588 total spaemployees in July 2007, compared with267,400 in August, 2006. Most of the declinewas in part-time employees, with 118,078 ofthe employees being full-time in 2007, 73,648being part-time, and 42,862 comprising con-tract employees. This is in contradistinction tofigures of 215,200 total spa industry employeesin April 2004.6

There are 7,340,000 medical spa entries whenGoogled currently, versus 224,000,000 under

the heading spa, which illustrates the public per-ception of medical spas, or, at the very least, theGoogle perception. The number of entriesindicates that ‘‘medical spa’’ has reached the ver-nacular and is highly sought out among typicalsearch engines.

TYPICAL PROCEDURES

Typical procedures offered at medical spas in-clude treatments ranging from microdermabrasionto laser treatments and massage. Many of theseare documented below, as well as ancillaryservices, such as product sales, which providewelcome income to the spas.

MICRODERMABRASION

Although the Merriam-Webster dictionary doesnot list this term, Wikipedia reports that microder-mabrasion is defined as:

A cosmetic procedure popular in day spas,doctors’ practices, and medical spas in whichthe stratum corneum . is partially or com-pletely removed by light abrasion. Differentmethods include mechanical abrasion fromjets of zinc oxide or aluminum oxide crystals,fine organic particles, or a roughened surface.Particles are removed through the wand/handpiece through which the abrasive parti-cles come.7

Microdermabrasion is used mainly to re-move minor skin imperfections and improveupon post inflammatory hyperpigmentation(PIH). It is not typically painful and can some-times be used for light scarring (mainly thatdue to PIH), but is ineffective for deeper formsof scars. While initial articles on microder-mabrasion in the dermatology literature sug-gested that collagen formation might occur,there has been no significant evidence inlong term studies of this. While it does tendto improve acne on a short term basis, longterm improvement isn’t likely, and it is notrecommended for at least 12 months afterisotretinoin use.

Initially, microdermabrasion was intro-duced with the use of lightly abrasive crystals.Now, there are other options including varioushandpieces with roughened surface. At thetime of this article, there are no regulationswhich mandate medical oversight of thisprocedure, and it is commonly performed innon-medical as well as medical spas. Whilecrystal systems using aluminum oxide or saltcrystals are still used, there are now diamondmicrodermabrasion systems, which operate


without the need for crystals. The exfoliationprocess results from the diamond tippedhead making contact with the skin and abrad-ing it. Both systems eventually suction thedead skin cells from the face.

Home microdermabrasion systems, pro-duced by the larger cosmetic makers, arenow entering the market. It remains to beseen if most people will have the disciplineor desire to use these systems rather thangoing to their local esthetician or day spa. Itshould be noted that these systems are lesspowerful than the other, spa oriented systemsand may have less impressive results than themore aggressive treatments.

ENDERMOLOGY

This procedure was introduced in the 1990s to theUnited States by a French manufacturer (www.endermologie.com) and has been a mainstay oftreatment for cellulite since that time. Althoughseveral other manufacturers have licensed ordeveloped technology that is similar, the mainconcept in all cases is the treatment of cellulitewith a suction mechanism and rollers that suctionin the fat/tissue and knead it in a rolling motion.Many medical spas offer this service, and thereare newer forms that are laser associated(Triactive, Cynosure) or use infrared applications(Velasmooth, Syneron). Although this procedureprovides a temporary benefit, the long-termbenefits are minimal unless maintenance proce-dures are continued.

LASER TREATMENTS

Although laser treatments are offered in manydermatology spas and medical spas, most ofthese are under the direction of, or are performedby, medical professionals. The average day spathat is outside of a dermatologist’s office is poorlyequipped to do these procedures. It is thisauthor’s opinion that many disservices havebeen done to patients by the inappropriate perfor-mance of these procedures by nonmedicallytrained individuals with little or no supervision, sothis article does not treat this topic in any depth,given the concerns with the operation of thesetreatments by nonqualified or underqualifiedindividuals.

BOTOX AND FILLER TREATMENTS

Although many medical spas run by or with fulloversight by qualified dermatologists offer theseservices, this is an area rife with misleading claims,

due to the many corporate-run day spas that per-form these treatments with poor results traceableto untrained individuals and little medicaloversight. It is this dermatologist’s fervent hopethat this problem will be addressed by the govern-ing authorities and medical review boards ona state-by-state basis.

MANICURES AND PEDICURES

These procedures are often done in day spas, andmedical day spas are no exception. They providemany patients a source of pleasure and can beeffectively performed in a much more sterile envi-ronment when done in a dermatology setting.Most salons do not carry tools such as autoclavesand even bactericidal trays that can render toolssterile. Many of the technicians performing theseprocedures have little or no education in steriletechnique. This has resulted in several high-profileinstances of contamination with mycobacteriuminfection in the baths or tools used for theseprocedures.8

In our clinic, we no longer perform this proce-dure due to poor reimbursement and the lack ofinterest compared with the price necessary tomake the procedure sterile and profitable. Thissituation is one that bodes ominous conse-quences for many who seek out these services ina nonclinical setting.

MASSAGE

Although massage is a mainstay of the destinationspa, most medical spas in nonresort towns mayhave less traffic for this procedure. Although weperform massage, it is not one of our main sourcesof revenue. The top 10 of the many differentforms of massage, according to about.com,9 areSwedish massage therapy, aromatherapy, hotstone massage, deep tissue massage, shiatsu,Thai massage, pregnancy massage, reflexology,sports massage, and back massage.

Swedish massage is the most common type ofmassage therapy in the United States. Usinglong smooth strokes, massage therapists kneadwith circular movements on superficial layers ofmuscle using massage lotion or oil.

Aromatherapy adds essential oils that addressspecific needs to the massage. The masseuseselects oils that are relaxing, energizing, stress re-ducing, and balancing, the most common of whichis lavender. Aromatherapy massage is used formany stress-related conditions and conditionswith an emotional component.

Hot stone massage involves using heated,smooth stones on the body to warm and loosen

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tight muscles. It is especially useful for those whoare seeking a more superficial massage.

Deep tissue massage targets the deeper layersof muscle and connective tissue. Using slowerstrokes or friction techniques across the grain ofthe muscle, the massage therapist kneads tightor painful muscles or muscles that have sustainedinjuries.

Shiatsu, a Japanese technique, uses localizedfinger pressure to simulate acupuncture pointmanipulation. Thai massage also uses gentlepressure on specific points, incorporating com-pressions and stretches. Pregnancy massage isan increasingly popular massage for expectantmothers. Massage therapists become certified inthis technique and may have special instrumentsfor this. Reflexology is a form of foot massagethat involves applying pressure to trigger pointson the foot that presumably correspond to organsand systems in the body.

Sports massage is specifically designed for peo-ple who are involved in physical activity, with fasterstrokes than in Swedish massage and with stretch-ing incorporated into the massage. Back massageis commonly performed solely during the treat-ment. Other techniques, such as Reiki and craniosacral massage, are beyond the scope of this arti-cle but are offered in some medical spas.10,11

WAXING

Waxing is a procedure that incorporates variouswaxes used as a short-term (2- to 8-week) depila-tory for unwanted hair. This is used in many salonsand medical spas for the patient who wishes re-moval of hair from facial, back, or bikini/leg areas.

PRODUCT SALES

Although any dermatology spa maintains its char-acter via procedures offered, the bulk of the profitsrevolve around product sales. These sales areoften made by the estheticians or the dermatologystaff in conjunction with the estheticians. It isimportant to have a product line that is excellentand that is embraced by the staff, or the saleswill lag. Additionally, it is important to have excel-lent oversight of inventory, sales records, taxreceipts, and product freshness.

Considering that many spas in the area beginstocking the same product once one spa intro-duces it, it is important to keep an eye on pricesin the community and other operations’ promo-tions to be competitive. Product sales are suchan important part of the operation that it is impor-tant to have a manager who agrees with the overallphilosophy.

Because certain employees of a spa may not bethe best at product sales, it is important to have‘‘closers’’ for the patients who may wish to pur-chase product but need assistance at the check-out counter.

WEB SITE

Any spa should have a Web site that allows forpatients to explore available options. These in-clude the potential to give a gift certificate, bookan appointment or inquire into booking an appoint-ment, and see a price list of procedures. Our Website has been a source of great PR for the day spaand is constantly updated. Additionally, we senda monthly newsletter to our patients via e-mailthat includes a special of the month.

GIFT CERTIFICATES

One of the biggest ‘‘products’’ of a Web site isthe gift certificate business, especially aroundthe holidays. Christmas and Valentine’s Dayprovide quite a bit of business for the rest ofthe year if gift certificate business is courtedand strongly received. Gift certificates are placedat locations within the office for easy access bypatients. There are many rules in different statesregarding gift certificates and the ways in whichthey may or may not be redeemed. Additionally,if they are not used, the office may be requiredto refund the money to the state. It is importantto check with your accountant to find out theanswers and proper procedures for your situa-tion. As for the appearance of the gift certificates,they may range from a handwritten certificate onembossed paper to a card that is credit-card-likeand entered into a system. Our office uses bothand can provide them depending on the wishesof the purchaser. Credit card companiesoften work with an office to make a very attrac-tive card.

THE FUTUREOF SPA DERMATOLOGY

This author is somewhat circumspect about theopportunities in the future for this part of derma-tology. Although I am personally enthusiasticabout the types of services provided in my clinicfor dermatology patients and for nonpatients viathe day spa, I am concerned that there aremany other spas in operation that are mannedby nonphysicians and/or nondermatologists orcore cosmetic surgery specialists that may beproviding less than optimal care for the public.In recognition of these concerns, this articlediscusses different outcomes based on the type


of dermatology spa experience offered in thefuture.

NONMEDICALLY SUPERVISED,FAUX-DERMATOLOGY SPAS

There are many more nonmedically supervisedspas than there are true, dermatology-run spas.In Omaha, Nebraska, there are at least five suchspas in operation, and more are coming. Theowners and operators range from physician assis-tants to emergency physicians to a dentist. Thecommon factor seems to be the desire on thepart of the owners/managers to leave their areaof expertise and dabble in dermatology, and theresults have ranged from misleading to disastrous.Many complications from these clinics have beennoted in the community, including poor results,scarring from inappropriately performed laser pro-cedures, infections from poor wound care after theprocedures, and poor advice regarding suchwound care. As a consequence of poor manage-ment and poor procedure technique, many ofthese clinics have gone bankrupt or are out ofbusiness. One has been cited for not followingstate regulations regarding who should performmedical procedures. At least one medical mal-practice suit has been filed against one clinic thatdid not carry malpractice insurance; this clinic isstill in operation.

It seems that these types of ‘‘faux dermatology’’clinics are here to stay, but it would be hoped thatregulations may force a modicum of services thatapproximate the high level of care that dermatolo-gists and other core specialists provide. This prob-ably will not happen without a huge amount ofwork on the part of dermatologists and the stateofficials overseeing these sorts of ventures.Although it has always been the practice in themedical profession to try to work with fellow prac-titioners whose results are not up to par, that willnot work for many of these clinics that have nooversight and are run by a corporate groupthousands of miles away that has no intention ofstepping foot in the town in which they operatethe clinic. They hire nurses or people with less orno credentials to administer the treatments andpocket the earnings for the corporation. This isthe type of disconnect that leads to disasterssuch as were mentioned previously.

In Florida, Dr. Mark Nestor spearheaded theeffort in 2006 to pass a bill to improve standardsin medispas. The bill was signed by GovernorJeb Bush. His accounting of the process isdetailed here (Mark Nestor, personal communica-tion, 2007):

The genesis of the Florida Legislation is that itessentially tightens supervision requirementsin all offices including Dermatology officesand med spas. The reason for the law is sim-ply patient safety issues. The physicians in thestate of Florida, as well as the board of med-icine were seeing significant problems withburning from lasers as well as problems withfillers and other issues. We had a total fiascowith Botox that was injected by a chiropractor(in Florida). The legislature and the board alsorecognized that there was extremely lack ofsupervision in the area of ‘‘medical spas’’and patient safety was significant concern.Based on this, the Florida Society of Derma-tology and Dermatologic Surgery as well asthe Florida Medical Association and multiplestate organizations and societies sponsoredwhat has been known as HB 699 or the‘Safe Supervision Bill’, which was signedinto law by Governor Jeb Bush and wentinto effect July 01, 2006. This bill essentiallysets new standards for physician supervisionof nurse practitioners and physicianassistants.

The bill limits the number of satellite officesthat a physician can supervise: four forprimary care, two for special care, and twoeventually phasing to one for offices offeringprimary dermatologic care, including thoseoffices offering primary aesthetic skin careservices. It also limits two main supervisorsatellite offices offering primary dermatologiccare. The physicians who supervise the satel-lite office offering dermatologic care (includ-ing aesthetic care or Med Spas) have to beboard eligible, board certified dermatologistsor plastic surgeons. This last aspect wasa reaction to multiple medical spas thatwere opening up and being supervised by re-tired radiologists.

This bill was fought vigorously by certainaesthetic laser companies but the FloridaSociety along with Florida Medical Associa-tion, with backing from the American Acad-emy of Dermatology and American Societyof Dermatologic Surgery prevailed and thebill was passed. The bill has been in effectand we feel that, to-date, there has beenimprovement in patient safety. At this point,there have been numerous violations thathave been identified and these violationshave been addressed on an ongoing basis.We feel that the Florida Society has donea great service for the patients in State ofFlorida who desire appropriately supervisedcare and safe treatment.

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This is one bright spot in a field where safety hasnot always been of paramount importance andlegislation has been weak or non-existent. Forsome of the spas, such as the aforementionedthat have a medical owner in state, that individualmay never be involved because he or she may bebusy in a practice, while the spa is being managedand operated by a noncredentialed employee. Thelabeling of the spa in these instances is oftenmisleading; terms like ‘‘dermatologic’’ and ‘‘skinpractitioners’’ are used, but no explanation of thequalifications of the people who perform the pro-cedures is offered. Finally, there are many talesof ‘‘cheap Botox’’ for $99 or less at these sorts offacilities, accompanied by the concern andfrequent reality that the Botox is watered downor, in some cases, bogus. The author notes themany arrests in the last Botox scandal at clinicssuch as these where ‘‘Chinese’’ Botox was beingsubstituted for the real Botox (as referenced inDr. Nestor’s note).

TRUE SPA DERMATOLOGY

The future of spa dermatology in which a dermatol-ogist provides care within their office or practiceand oversees the everyday activities of the spaseems bright. Dermatologists coming out of resi-dency have never been more interested in thesesorts of endeavors and have never been exposedto as much cosmetic dermatology as they are nowtaught in their programs and after their entranceinto practice. Organizations such as the AmericanAcademy of Dermatology, the American Society ofDermatologic Surgery, and the American Societyof Cosmetic Dermatology and Aesthetic Surgeryoffer numerous opportunities for dermatologiststo learn more about this field. Additionally, compa-nies are providing more opportunities for educa-tion, and product selection for lasers/equipmentand cosmetic/cosmeceutical products is at anall-time high. The boom in such procedures andconcurrent interest among prospective patientshas spurred larger numbers of companies, whichcan only improve the options available.

The challenge for the practitioner, and for thedermatologist in particular, is how to run thistype of facility in a profitable and personallyrewarding manner. There are many facilities thatare not able to survive in the current environment.This may be an opportunity for the dermatologistwho is willing and able to provide these servicesfrom within or near their clinic.

The dermatologist in practice has a natural ad-vantage over the nondermatologist because heor she has a built in base of patients who knowthe quality of the clinic’s services and have seen

them for other, related concerns. It is my opinionthat this makes the dermatology practice–runspa a higher-quality entity in the public mind thanthe spa that is run by a nurse, noncore cosmeticMD, or less. On the other hand, the public needsto be educated on the differences or they may as-sume that a pretty spa with a clean look translatesto good medical practice. As many dermatologistsknow, this could not be further from the truth.

Starting a dermatology spa in the future is goingto be easier than ever before due to companysupport and a population of estheticians that iswilling and interested in working for a dermatolo-gist. This is evidenced by the creation of maga-zines solely devoted to estheticians working inmedical practices (PCIjournal.com, medesthe-tics.com). My staff has improved greatly over theyears as a consequence of improved training ofestheticians, and I expect the quality of estheti-cians to improve more with time. Additionally, theesthetician schools and magazines are moreaware of the natural alliances between estheti-cians and dermatologists than they were in thepast. When I started my medical day spa, therewas a lack of trained estheticians who were willingto consider working for a dermatologist. We havemany more applications than we ever did before,including applications from trained staff with over12 years of experience.

With the lines between dermatology- and non-dermatology-related services blurring, it is goingto be increasingly important to market serviceswell and make sure that the public knows theimportance of seeking a professional who dealsin skin issues on a daily basis. This is essentialfor the field to continue to be held in high regardby the consumers and patients.

It is necessary for practitioners to investadditional time and effort to ensure that safety isof paramount importance. This may mean self-regulation of spas that may not be performing upto medical standards or provision of legislation toinsure regulation. With proper attitude and involve-ment of dermatologists on all levels of medicalspas, the future of spa dermatology should remainbright.

REFERENCES

1. Available at: www.about.com http://spas.about.com/

cs/spahistory/a/spahistory.htm. Accessed 2007.

2. A brief history of spas. Available at: http://www.spa

finder.com/spalifestyle/spa101/history.jsp. Accessed

2007.

3. Available at: www.about.com http://gojapan.about.

com/gi/dynamic/offsite.htm?zi51/XJ&sdn5gojapan&

cdn5travel&tm510&gps5210_231_788_421&f500&

http://spas.about.com/cs/spahistory/a/spahistory.htm

http://spas.about.com/cs/spahistory/a/spahistory.htm

http://www.spafinder.com/spalifestyle/spa101/history.jsp



http://gojapan.about.com/gi/dynamic/offsite.htm?zi=1/XJ&sdn=gojapan&cdn=travel&tm=10&gps=210_231_788_421&f=00&su=p531.31.152.ip_p531.29.420.ip_p284.8.150.ip_&tt=2&bt=0&bts=0&zu=http&percnt;3A//www.east.co.jp/oyu/english/




su5p531.31.152.ip_p531.29.420.ip_p284.8.150.ip_&

tt52&bt50&bts50&zu5http%3A//www.east.co.jp/

oyu/english/. Accessed 2007.

4. Myth 49: you can catch a variety of infections,

including sexually transmitted diseases, in spas at

public facilities—Gauging The Truth. FindArticles.

com. Available at: Pool and Spa News Oct 30,

2002; http://findarticles.com/p/articles/mi_m0NTB/

is_21_41/ai_94160731. Accessed November 18,

2007.

5. Are medical spas for real? Available at: http://

www.medscape.com/viewarticle/496073. Accessed

2007.

6. New ISPA Research Reveals Day Spa Revenues

Down, Medical Spa Revenues Doubled From

SPATRADE. Available at: www.Spatrade.com http://

www.spatrade.com/news/index.phtml?act5read&id5

642. Accessed August 13, 2007.

7. Wikipedia.com. Available at: http://en.wikipedia.org/

wiki/Microdermabrasion. Accessed 2007.

8. University of Wisconsin website. Available at. http://

www.bact.wisc.edu/Microtextbook/index.php?name5

Sections&req5viewarticle&artid5320&page51.

Accessed 2007.

9. About.com. Alternative medicine. Available at: http://

altmedicine.about.com/od/massage/a/massage_

types.htm. Accessed 2007.

10. About.com. Available at: http://altmedicine.about.

com/od/reiki/a/reiki.htm. Accessed 2007.

11. Ezine articles. Available at: http://ezinearticles.com/

?Craniosacral-Massage—The-Benefits&id5275274.

Accessed 2007.




http://findarticles.com/p/articles/mi_m0NTB/is_21_41/ai_94160731



http://www.medscape.com/viewarticle/496073



http://www.spatrade.com/news/index.phtml?act=read&id=642



http://en.wikipedia.org/wiki/Microdermabrasion

http://en.wikipedia.org/wiki/Microdermabrasion

http://www.bact.wisc.edu/Microtextbook/index.php?name=Sections&req=viewarticle&artid=320&page=1




http://altmedicine.about.com/od/massage/a/massage_types.htm



http://altmedicine.about.com/od/reiki/a/reiki.htm

http://altmedicine.about.com/od/reiki/a/reiki.htm

http://ezinearticles.com/?Craniosacral-Massage---The-Benefits&id=275274



Dermatologic Clinics - Spa Dermatology (Vol 26 Issue 3, Elsevier, 2008)

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Transcript of Dermatologic Clinics - Spa Dermatology (Vol 26 Issue 3, Elsevier, 2008)