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