Super Specialization in Dermatology Benefits Us All

If we celebrate those who subspecialize in “medical” aspects of dermatology, then we must acknowledge the value of a true cosmetic specialization—for our patients and our specialty.

By Suneel Chilukuri, MD

Our capabilities as dermatologists have grown tremendously over the past 20 years and continue to evolve. We now routinely prescribe immunologic therapies for debilitating conditions, such as full body psoriasis and severe eczema. Our toolbox to treat advanced melanoma and nonmelanoma skin cancer has also grown. Similarly, our capacity for surgical and nonsurgical in-office procedures continues to develop. In addition to now “routine” Mohs micrographic surgery, liposuction, and in-office mini-face lifts and brow lifts, dermatologists continue to expand nonsurgical rejuvenation capabilities for our patients. As a result, some of our board-certified dermatologists have chosen to exclusively practice cosmetic dermatology. Is this wrong?

Many things today’s graduating residents take for granted were not available even a few years ago. For example, while every resident is now tested on various oral and topical inflammatory inhibitors and even gene therapy, these concepts were fictional in 1999. Similarly, our ability to tighten and lift the face and neck without surgery was limited 20 years ago. Today’s patient receives many effective nonsurgical options that delay and/or enhance their surgical options.

With rapidly evolving technology in the cosmetic space, the true cosmetic expert must understand how to fully utilize and customize a treatment plan for his or her patient. There are currently more than 200 fillers being used worldwide, of which 19 are FDA-approved for use in the US. Does the general dermatologist understand the clinical nuances of each one? Does your patient need a hydrophilic hyaluronic acid (HA) filler for anterior projection? Does your patient need an HA filler that will integrate into the dermis with almost no trace? Should you start with a collagen stimulator, such as poly-l-lactic acid? What is the role of dissolving suspension sutures? Does your patient’s physical activity help guide your decision? Does your patient’s occupation change your treatment plan? At what stage should you add neuromodulators? When should you add technology, such as radiofrequency (RF), ultrasound (US), combined RF with unfocused US, microneedling, RF microneedling, ablative laser, nonablative laser, or hybrid laser? Should skincare be started before the procedure or immediately after the procedure? If before, how long should the skin be prepped with a topical product to optimize results of the recommended procedure? Where do professional grade topicals work better than prescription products? These questions are just a few that a cosmetic dermatologist answers in the span of seconds when he or she examines a patient.

As with any field that is changing so quickly, not everyone is going to be an expert. An expert is defined as a person who has a comprehensive and authoritative knowledge of or skill in a particular area. To have comprehensive knowledge, a dermatologist should test and have extensive experience with every product currently available.

Don’t condemn those who choose to be the true expert in a particular aspect of dermatology. This allows referrals to the best possible dermatologist for care based on the patients’ needs. No one would criticize a colleague for referring someone to a melanoma, dermatopathology, pediatric, or psoriasis expert. We accept and appreciate subspecialization within “medical” dermatology; why is cosmetic dermatology any different? Any emphasis placed on advancing the science of skin health and the highest levels of patient care raises and supports our specialty and should never be construed as diminishing it.

The Versatility of Dermatology: The Best of All Worlds

One dermatologist shares how his shift from a primarily medical practice to a group of practices offering everything from pediatric dermatology to aesthetic treatments made him appreciate “missed opportunities.”

By Bobby Buka, MD, JD

We opened our first dermatology practice, Bobby Buka MD, in downtown Manhattan in the Summer of 2007. Over the following 10 years, we grew to seven locations before merging with a smaller, like-minded group to become The Dermatology Specialists (TDS), a full-service dermatology practice in New York City with 12 locations across Manhattan, Brooklyn, and Queens.

I completed a pediatric dermatology fellowship at the Rady Hospital at UCSD with a plan to return to the East Coast and join a larger dermatology group practice. The hope was to just focus on pediatric dermatology. I recall refusing to see adults at my first job in New Jersey—no one over the age of 18! Pediatric derm was first really compelling to me, because children are the most appreciative of our patients. Outcomes are outcomes, and a more comfortable child never required serial photography or an EASI score to prove it. She slept well for the first time in weeks or could concentrate better in school. To this day, caring for this patient population is some of my most rewarding work.

When I moved to New York, the strategy was to stay focused in pediatric derm. I soon found that other family members sought dermatologic care as well. You know: “While we’re here, can I quickly also show you something on my husband’s arm?” Before Zocdoc, before Google SEO, the practice doubled in size each year just from word-of-mouth.

If you instill trust in your patients when you treat their rosacea or their acne or psoriasis, it’s likely that in six months or a year, that same patient might say, “My friend was telling me about Botox—do you do that too?” And for me, that’s the best kind of engagement—historical conversion of an existing patient rather than recruiting a patient from social media or a well-placed Adword or because you’ve got the shiniest laser tech. That’s how our aesthetic practice first grew—proficiency in our medical specialty and then extending to the cosmetic, elective elements of skin health.

I smile now when dermatologist-colleagues say, “I’m a Mohs surgeon—I refuse to do excisions,” or “I’m an aesthetic dermatologist—I will not perform skin cancer screenings.” It reminds me of my own “only pediatric dermatology” days, but also reinforces the importance of embracing the various elements of our specialty.

The diversity of our specialty that spans from cancer to aesthetics is not only vital for the survival and integrity of our field, but also affords a beautifully prolific day for the dermatologist who embraces all of his or her education. To give up any single aspect of one’s training, I believe, is a missed opportunity to capture the full scope of our specialty.

It is certainly possible today to have a private practice singularly devoted to injectables or skin cancer or even pediatric dermatology, but reimbursement margins are getting tighter, payor panels are closing, urban per-capita dermatologists are rising, and economic uncertainly is just an administration away. You’re a well-trained dermatologist, with solid residency cases under your belt, so why paint yourself into a corner? The very nature of our dynamic specialty affords us the opportunity to practice broadly. You may prefer surgery or fillers to another aspect of our field, but why not cast a wide net—especially as you start out? There’s plenty of time to hyper-specialize later in your career once you’ve first built an expanded platform of care.