Changing face of dermatology – A paradigm shift

Nearly three-and-half decades back, I joined dermatology at Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India (1986–1989). Focus on that time was on diagnosis and treatment of skin disorders, one may now refer to as medical dermatology. After postgraduation, I was in Lady Hardinge Medical College (LHMC), New Delhi, as a Senior Resident in the Department of Dermatology and Venereology (1989–1992). Here I got to know the latest going on in New Delhi. Monthly meetings and updates were routine besides hospital indoor and outdoor work.

I joined Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, in 1994. Two years later, when I was Associate Professor and Head, I had a chance to make the department vibrant, visible, and to introduce new treatment modalities. Dr. CR Srinivas, Professor, and Head, PSG Medical College, Coimbatore, visited our department in early 2000 as Visiting Professor and conducted live dermatosurgery workshops to demonstrate punch grafting, split skin grafting, surgical treatment of adherent (by subcision), and nonadherent acne scars (by TCA cross or dermabrasion). I made a list of surgical instruments to be put in our department’s minor operation theatres to start surgical procedures. Subsequently, blister grafting and punch grafting became regular procedures for repigmentation of stable vitiligo, mainly focal and zosteriform vitiligo. Punch grafting was compared with blister grafting for lip vitiligo. This paper in the Dermatologic Surgery journal got broad appreciation.

Dermatosurgery clinics started in 1996, and lasers were procured in 2009, setting the tone for laser and cosmetic dermatology. The initial focus was on laser hair removal and treatment of melasma by using lasers. Dr. Laxmisha Chandrashekar was a resident doctor during 2002–2005 who got interested in dermatosurgery procedures and published several papers with innovations.

Until 2010, the JIPMER Dermatology department had only three faculty members [Dr. DM Thappa, Dr. Mariette D’Souza (shifted to Maulana Azad Medical College, New Delhi in 2008), and Dr. TJ Jaisankar]. Subsequently, Dr. Laxmisha Chandrashekar (2010), Dr. Rashmi Kumari (2011), Dr. Nidhi Singh (joined in 2013, but resigned in 2015), Dr. Malathi M (2014), and Dr. Sivaranjini R (2017) joined as faculty members. More postgraduates from the female gender preferred dermatology, and dermatology became the first choice for postgraduation. The department of dermatology introduced a fellowship course in laser and dermatosurgery (of one year) with a well-developed curriculum at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Puducherry, India, in 2017. Already two batches have passed out since then.

Cosmetic dermatology (aesthetic medicine/medical aesthetics) has now been recognized as an emerging sub-specialty of dermatology.^[1] Dermatologists have supremacy over other aesthetic practitioners as they also treat visible as well as stigmatizing skin disorders. More and more procedures are being introduced in cosmetology. Some of these procedures can be applied as therapeutic options for the treatment of hyperhidrosis (botulinum toxin), post-inflammatory hyperpigmentation (chemical peels), hair removal for grafted skin (lasers), etc. Thus, cosmetic dermatology has become a need of the hour but with the well laid down curriculum too.^[1] In the last two decades in India, more and more women are taking up dermatology to pursue aesthetic practice. Women in dermatology have started their association, the Women’s Dermatologic Society (WDS), and their journal, International Journal of Women’s Dermatology (IJWD). The WDS was founded in 1973. It is primarily dedicated to the personal and professional development of women dermatologists to achieve high-quality patient care services. Their journal, IJWD, discusses skin and cosmetic problems in women.

The past five decades have seen a significant shift in women’s representation in dermatology in western countries.^[2] Similar trends are also visible in India. Women practicing dermatology have increased from a meager 15% in the 1960s to 50% in 2001 as per American Medical Association. Some of the women leaders of dermatology, such as Rose Hirschler (the first woman dermatologist) and Wilma Bergfeld (the first woman president of the American Academy of Dermatology), were at the forefront of this change. Naomi Kanof rose to prominence in the field of dermatology by becoming the first woman editor of the Journal of Investigative Dermatology.^[2] In India, late Professor Surrinder Kaur, from Chandigarh, Prof. Hemangi Jerajani, from Mumbai and Prof. Rashmi Sarkar, from Delhi led the women dermatologists.

The type of dermatosurgery procedures in 1990 was initially focused on electrosurgery, radiofrequency ablation, surgical excision of benign skin tumors/lesions, and vitiligo repigmentation surgery, which have changed now in their profile. Instrumental for this phenomenon were Dr. Satish S. Savant from Mumbai, India, one of the founder dermatosurgeon in India, who inspired many of us to perform dermatosurgery in their daily practice, and Dr. Subrata Malakar (Director, Rita Skin Foundation) from Kolkata, India who took the lead in promoting dermatosurgery in India by organizing workshops and publishing books. Over the years, anti-aging procedures like chemical peels, botox injection, and laser resurfacing were introduced. Hair transplantation has become a new entrepreneur business for male dermatologists. Now cosmetic clinics, aesthetic clinics, chain clinics (Kaya, Vandana, and Luthra), and Skin city have come up in all nooks and corners of India. Hotels have established aromatherapy and SPA centers with body massage and detox therapies mostly run by womenfolk.

In cosmetic surgery (aesthetic surgery) practice in 2005 in the USA, surgical methods were nearly 20%, and nonsurgical methods were up to 80%.^[3] Botox injections, laser hair removal, hyaluronic acid filler injections, microdermabrasion, and chemical peels were the top five nonsurgical cosmetic procedures. Nearly 90% of cosmetic procedures were performed in women. Men had almost 10% procedures. Most procedures were performed in the young and middle age groups. Those between 51 and 64 years accounted for 24%. Increasing awareness regarding aesthetic procedures has led to a range of skin care products in the aesthetic menu, skin rejuvenation, hair, wrinkle, scar, stretch mark, cellulite, tattoo, and pigment removal, hair transplantation, skin lightening, and body sculpturing by removal of fat. Nonmedical aesthetic practitioners (such as beauticians and spa operators), besides dermatologists and plastic surgeons, have entered to provide these services. Many of these cosmetic procedures to rejuvenate the skin are not scientific. Advertising in media promotes consumption of various cosmetic procedures and products for skin rejuvenation and skin lightening. Unethical use of them is thus promoted. Topical use of corticosteroids as fairness cream in India is an offshoot of the same and over-the-counter availability of medicines has made things worse.^[3]

Fair skin is thought to be equivalent to beauty.^[4] In India, obsession with skin color has a long history. Fairness of skin gives prestige and attractiveness to both genders, and for women, increased matrimonial prospects. This desire for fairness has led to all kinds of treatments to achieve a desirable skin color. In Asia, skin whitening products account for 60% of sales of skincare items. Roughly 60%–65% of women use some form of skinlightening product in their daily routines.^[4]

Nowadays, aesthetic surgical procedures are done with a motive to earn profits.^[5] Aesthetic surgery has become blind to the real needs of patients and has become part of the beauty industry. Youthfulness and personal success being given more prominence.^[5]

Cosmetology has achieved tremendous interest in the world, especially in the United States of America.^[6] Much of its recent recognition is due to scientific research in the development of imaging techniques, drug therapy, and other nonsurgical methods. The aging process in males known as andropause has now been recognized, and hormone replacement therapy is being offered. Botulinum toxin A (BTXA) therapy has become well-established for face wrinkles. It has become a valuable tool for brow lifts. The use of fillers with BTXA is another exciting option. Cellulite, a common and disfiguring condition in women. Recently, a scientific approach has led to its improvement. Lipotransfer and lipolysis are effective tools in body sculpturing, finding their way in managing other skin conditions such as bromidrosis, lipomas, stretch marks, scars, etc. Cosmetic dermatology is evolving into a scientific subspecialty of dermatology.^[6]

Most skin diseases are potentially stigmatizing because they are visible.^[7] Yet skin diseases, especially hair loss, are often deemed cosmetic, leading to undertreatment by clinicians and substantial psychological and financial burdens. The skin diseases considered stigmatizing are mostly leprosy, alopecia, vitiligo, and others visible.^[7] In addition to treating neoplastic disease, inflammatory skin disorders, and allergies, aesthetic dermatology has grown to become an essential issue in dermatology.^[8] Aesthetic dermatology puts medicine in a field of tension between medical necessities and patients’ wishes. Aesthetic issues are most relevant to dermatology because the skin is not only a functional organ like the heart, liver, and kidneys but a medium also of visual and tactile communication. The desire for beauty and youth is often expressed by patients and customers seeking advice on improving their appearance and looks. Aesthetic medicine means a significant challenge to the dermatologist because request and reality must be brought together and ethical thoughts kept in mind. With its new approaches to molecular biology and biophysical technologies (e.g., laser technology), modern medicine has opened up many new therapeutic possibilities for dermatologists that were essentially unimaginable until recently. Aesthetic dermatology has enriched dermatology and will not become a burden if we integrate aesthetic issues into medical strategies in a sensitive, evidence-based, and critical fashion.^[8]

The focus in dermatology is shifting gradually from diseased skin to desired skin that people prefer. Hence, the journal CosmoDerma, gives cosmetology its due place. Moreover, there is an increase in the anti-ageing population in this world who don’t want their face wrinkles and aging skin changes. In the absence of world wars in recent times and the increasing longevity of man, the cosmetic industry/aesthetic industry is surging ahead despite the COVID 19 pandemic.

Accreditation system to regulate cosmetology practice needed to be put in place in all countries.^[3] Many cosmetology practitioners are inadequately equipped to perform aesthetic procedures. There is a need for structured training and accreditation for cosmetic dermatology, aesthetic surgery, dermatosurgery, the use of lasers, and hair transplantation. “Do No Harm” should be the guiding principle for aesthetic practice.^[3]