A Modern Epidemic of Dermatology Quackery in India

Introduction

The practice of promoting medical remedies and surgical abilities by non-experts, to a gullible public is not a new concern. Records show the prevalence and flourishing of such acts in playing a large part in influencing the history of medical practice as early as 1750 to 1850.[1] Public perception of such remedies being seen as harmless or safe meant that those cases escaped liability very often, even though a considerable number were noted to be fake and dangerous.

Misleading and alternative medicine continues to this day, with many such practitioners being integrated into mainstream modern medical institutions and healthcare establishments. While some of the practitioners have forayed into it because of gaps in filling up specialist posts in resource-scant areas, many others have been absorbed into the corporate healthcare system in a bid to cut costs and save operational charges, while also compromising on the overall health and care of the community. In medical science, the effect of foraying into a specialized branch by others appears notably to be higher in dermatology. With the rise of aesthetics in dermatology and the proliferation of centres catering to concerns related to hair, nail, and skin, the practice of dermatological sciences has been impacted due to patients receiving care at the hands of unlicensed individuals. Resultant consequences of mishandling/mistreating cases, faulty diagnoses, and incorrect prescriptions have created a bizarre and confusing scenario of a multitude of persons posing as skin specialists.

Dermatology Practice and the Non-Dermatologist

Besides modern medicine, there are various other forms of medicine where human health and illnesses are studied. These are meant to coexist without “cross-pathy”, meaning one form of medical practice cannot prescribe/practice that of the other. AYUSH practitioners are those trained in Ayurveda, Yoga, Unani, Siddha and Homeopathy respectively, and comprise other systems of medicine, not involving modern medicine. While it may be argued that a lot of AYUSH-trained individuals are filling the gaps in rural healthcare and as assistants to medical officers, it has been shown that the distribution of such individuals is far higher in urban settings, contrary to belief.[2] This unethical practice also leads to disharmony among different specialties and the overall status of community health. Unqualified medical practitioners (UMPs) are those individuals lacking any recognized medical qualification and work in close coordination with qualified doctors who first train them as assistants, in an effort to reduce financial strain.[3] This has translated into many of them working in dermatology clinics or aesthetic centres, even setting up independent practices after having gained insight into procedures such as hair transplantation, chemical peels, LASERs, etc.

The above practitioners are neither qualified nor licensed to practice modern medicine in any branch of medicine. Thus, any person indulging in the practice of modern medicine in the field of dermatology, without having a licensed, recognized qualification/degree in the subject may be deemed responsible for perpetuating quackery in the domain of dermatology.

Quackery is, however, a broad/umbrella terminology and may be considered a spectrum, defined as the promotion and practice of the science of dermatology without the license to do so. On one hand of the spectrum is easily identifiable deception in the form of displaying unlicensed or fake and misleading qualifications and degrees, or writing and prescribing modern medicine, after having been trained in other forms of medicine, while on the other hand of the spectrum lies those who have been trained in modern system of medicine, including specialty and super specialty subjects, who choose to practice only dermatology, without actually having undergone residency training in dermatology. Labelling oneself as a dermatologist or skin specialist without having any pre-requisite, or having undergone training following MBBS is also untenable. A doctor having done residency in another field of specialization cannot label himself/herself as a dermatologist.

MBBS graduates in practice

While MBBS doctors can screen and treat basic, common medical conditions by prescribing medicines which are taught in their undergraduate courses as per the Medical Council of India (MCI)/National Medical Commission (NMC) curriculum, carry out basic procedures/assist specialists in practice, and help in administrative work, possessing only MBBS degree is insufficient to call oneself as a specialist, or label one as dermatologist/skin specialist. They cannot perform specialized procedures like dermatologic surgeries, laser treatment, etc., in which he/she has not been adequately trained, by post-graduate residency, or fellowship after post-graduation.

Misleading terminologies

Usage of words like ‘cosmetologist,’ ‘aesthetician,’ ‘aesthetic physician,’ ‘cosmetic surgeon,’ ‘trichologist,’ ‘skin-care expert,’ ‘hair expert’ etc., by innumerable persons in the garb of a skin specialist has added to the complexity of the situation. In this regard, it is notable to add that many qualified and licensed dermatologists are also users of such terminologies. The lay patient and the public in general, have no way to discern who is truly a dermatologist or not. Additionally, the use of manufactured and non-recognized acronyms and display of ‘degrees’ by non-specialists, competes with very similar-looking recognized degrees, namely, MD/DVD/DDV/DNB. It is not wrong to say here, that the mechanisms in place and public awareness to look for recognized degrees is not an easy task for the patient, especially one that is not attuned to the Indian system of medicine and the various degrees conferred. A public directory through iadvl.com is present wherein one can look up qualified members. A stringent and foolproof, wide-impact directory system is, however, still lacking at present. An aesthetic practitioner may have attained a certificate, diploma or masters’ courses that often involve online or distance learning. Qualifications such as MSc Derm (Masters), which some aesthetic doctors possess do not mean specialist accreditation in dermatology.

Impact of Social Media on Quackery

In his book Health for Sale: Quackery in England 1650-1850, Porter analyzed quack culture as having been inspired by contemporary publicity material, and labeled it as pure theatrics. Donning eye-catching wear, a hired clown would amuse the audience with tomfoolery.[4] Similar theatrics are in question again, in the present age of social media, with universal access and presence of healthcare professionals on various social media platforms. The lines have blurred between the real dermatologist, vis-a-vis beauty and skin influencers’ profiles, particularly on applications such as Instagram. This has added to the existing murky situation. Rampant promotion of skin and hair care products involving paid promotions, demonstration of procedures such as chemical peels, administration of injectable fluids including usage of IV glutathione, and playing into the hands of trending market and algorithmic forces by not just unqualified practitioners but dermatologists too, has made it difficult to educate masses on who is truly a licensed skin doctor. While social media is a wonderful tool that can be rightly used to improve community health and awareness; its misuse, on the other hand, with the sole intention of self-promotion alone, would point to concealed motives of patient solicitation. Clause 5.1 of the Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002 states that “Physicians, as good citizens, possessed of special training should disseminate advice on public health issues.” 6.1.1 states that “Soliciting of patients directly or indirectly, by a physician, by a group of physicians or by institutions or organizations is unethical.”[5]

Felt needs and demands of stricter regulations on aesthetic procedures

While surgical interventions are seen as riskier, safeguards are not in place in India. Therefore, dermatological procedures necessitate regulations. It is anticipated that the greatest risk and need for enhanced protection are among the more potentially invasive and expensive procedures of injectables and lasers. Both surgical and non-surgical interventions need sufficient regulation to ensure patient safety. Industry practices have dictated the evolution of aesthetic injectable awareness and the increase in demand of cosmetic enhancement procedures. Many injectables are being done by “injectors,” and an upward trend of energy-based devices and injectables being available at salons is being witnessed. Complication rates are on the rise, due to the “home-delivery” of devices for laser hair reduction (LHR), home-care kits involving peeling agents, and mobile applications encouraging self-diagnosis. We firmly believe that the mentioned procedures constitute the practice of medicine and that the provision of medical services, or practice of medicine requires the establishment of, and maintenance of professional standards. Training adequately in a specialty and getting a degree in the subject trained for is a prerequisite for practicing as a qualified and recognized specialist. Dermatologists are specialized experts who learn in-depth about the skin, mucous membranes, skin appendages like hair, dermal glands, and nails, and their interaction with all organ systems of the human body. Management of diseases of the skin and hair and loss of aesthesis needs evaluation of the entire body with knowledge of skin in detail as many conditions may appear clinically indistinguishable from one another, to the untrained eye. The line of management differs from case to case and is dependent on systemic evaluation and correct diagnosis. Only a trained and qualified dermatologist through evaluation can discern various modalities of treatments, which includes not just doing the procedures but knowing when a medical or surgical intervention is required, or contraindicated. Procedures such as hair transplantation is not just a mechanical job, but require thorough expertise on hair disorders, indications, contraindications, and management of complications of the procedure. Similarly, aesthetic procedures being done on the skin for indications such as pigmentary concerns, rhytids, loss of eyebrows, etc., may seemingly appear as cosmetic correction on the surface. However, each case needs careful examination and evaluation, which can only be gained after years of learning and training, even beyond attaining licensed degrees.

History of ITAQ, concerted efforts and new beginnings

Taking note of the alarming rise in the number of unqualified people posing as dermatologists, thereby putting common people at risk of getting inadequate or wrong treatments, the Indian Association of Dermatologists, Venereologists, and Leprologists (IADVL) task force against quackery (ITAQ) was formed solely out of urgent necessity. To curb the exponential rise in misrepresentation of dermatology, interpreting to real-world mishandling of patients, wrong diagnoses, faulty treatments, and increased complication rates, its framework of functioning involves active help of IADVL members in reporting unlicensed and unqualified practitioners, using a mailing system with photographic evidence and details of involved personnel. Being an evolving model, with the unique task of having to deal with this special area, the committee has had its fair share of learnings and inadequacies. To date, it seeks the coordination of national and state representatives to amplify concerted efforts and increase awareness at all levels, involving state medical councils, Indian Medical Association (IMA), and government ministries.

Dermatology education and building skilled practitioners

Efforts and directives to strengthen dermatology education in all medical colleges across the country will enable trainees to be better-equipped skill-wise and in theory. Curriculum upgrades including topics about aesthetics (injectables such as toxins, fillers, LASERs) need to be inculcated. A strong ethical code of conduct, if imparted to young trainees may enable graduating residents to deal with real-world moral dilemmas in practice. This includes the prohibition of teaching laymen and other professionals, the subject of dermatology. Imparting technical knowledge to unskilled or semi-skilled personnel will only help the proliferation of pseudoscience and quackery in the field, and violates the Indian Medical Council/NMC Act 1956 and of the Indian Medical Council/NMC-Professional Conduct Etiquette and Ethics Regulations 2002.[6] NMC draft guidelines remind RMPs that medical treatments must be done keeping in mind the best interests of the patient.[6] Baumann reflects on the changing trends in cosmetic practice, where daily opportunities for financial gain are aplenty, thus challenging a physician’s ethics.[7] A recommendation paper or guideline on social media ethics and etiquette would enable some clarity in this regard.[7] Disclosures of trade names, molecules, and drugs on social media for content creation are causing additional promotion of harmful practices impacting healthcare outcomes. They include immunosuppressives and immunomodulators, and small molecules which need strict screening tests and monitoring and are associated with systemic complications. As guardians of public and community health, remaining mute on dangerous practices will be a collective undoing for global dermatology health. The epidemic-like situation of dermatophytosis, misuse of antifungal drugs, and topical corticosteroid menace, involving combination formulations is a fall out of unrestricted access to prescription medicines by patients and treatment by non-skin specialists.[8]

Artificial Intelligence

The ubiquitous presence of artificial intelligence (AI) is beginning to disrupt healthcare systems. E-commerce websites based on consumer targets and direct selling through “influencers” have been proven to impact skin health by misleading advertisements and sponsored deals. Augmented reality on social media applications such as Instagram, which promotes selfies and filter culture has increased body image issues, with young adolescents seeking home remedies and aesthetic fixes, though long-term effects are yet to be noted.[9] Large-scale investment in aggregator platforms promoting free and inexpensive virtual consultations for common dermatology conditions/symptoms, such as acne and hair loss, is an unwanted ramification of AI in medicine. Many potential pitfalls remain to be addressed.[10]

Limitations

The legal system lacks well-defined laws applicable to medical quackery, and dermatology. Stringent regulations on the pharmaceutical industry and dermatology device providers would enable patients to access the appropriate treatment provider. Defining the scope of work by licensed dermatologists may enable a means to demarcate one from an unlicensed individual or organization. A unified approach to integrating dermatology services and promoting all aspects of the subject, including immunodermatology, dermatopathology, dermatoepidemiology, geriatric care, sexually transmitted infections (STIs), and interventional dermatology, remains crucial. This is not to be confused with a multidisciplinary approach to treatment and care, where different specialties tackle cases together to provide a comprehensive approach to diagnosis, treatment, and care for better outcomes; and is beyond the scope of this focussed narrative.

Conclusion

The dilution of dermatology practice is impacting the representation of the branch as it is being increasingly viewed as that of cosmetic and beauty enhancement only. Challenging the status quo on the issue of quackery is a multi-level affair. Acknowledging the problem, and grasping the consequences of allowing rampant marketing of clinics and centres posing as skin clinics, as detrimental to the health of society, is most important. A horizontal approach, involving association members, and local administrative bodies, and a vertical approach by liaison with ministry and government regulatory bodies, as well as state and national medical councils is needed. Members need to pick the pace up at the ground level, improve public awareness of the true skin, hair, and nail experts, and release regular notifications and write-ups in print and social media, while also ensuring that members maintain high-quality clinical expertise and care.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.