Clinical innovations - Of Demographic and Perceptual Innovations: Brown Spots, Botox, and Erasure and Removal of Skin Lesions

In Innovation and Entrepreneurship, Peter F. Drucker says changing demographics and perceptions offer unprecedented innovative opportunities. This holds true for medicine, as well as business.

Changes in demographics – defined as changes in the population – are predictable. The U.S. population is aging. Aging will impact what services will be demanded – and offered. Skin changes of aging – wrinkles, brown spots, keratoses, skin tags, sagging, unsightly hair, and skin tumors – are more visible and are more apparent than aging changes in other organs.

Changes in perception may be more subtle. But no doubt there has been a change in how we view aging. “Sixty, “it is said, “ is the new forty.” Translated, this means we never want to grow – or look old. This change in perception has created a vast market for health –care magazines, alternative medicine, physical fitness centers, other “wellness” services, cosmetic surgery, Botox injections, and erasure or removal of irritating skin blemishes or lesions telegraphing age.

Brown Spot Day

The other day I was talking to a medical school classmate who heads up a group of five internists in Maryland. While serving in the U.S. Army, his medical post had a “brown spot day.” That day occurred once a month, when he and his medical colleagues could commandeer a flask of liquid nitrogen from the commissary. The Army doctors used the precious liquid nitrogen to “freeze and kill” brown spots, usually seborrhea keratoses or other unsightly ski lesions, such as warts.

Today my classmate and his four partners have a tank of liquid nitrogen in the hallway adjoining their offices, and they use the liquid nitrogen to “freeze and kill” skin lesions in civilian patients. He says they are “very careful” about which lesions to freeze.

They know full well not to freeze something that might represent a malignant melanoma or basal or squamous cell carcinoma. They refer any suspicious lesion directly to the dermatologist. He and his partners are sometimes reimbursed for their work, but not always. Instead their purpose, he says, is to please patients and save them time and expense by doing the freezing while patients are in the office.

Botox Injections

The internists do not inject Botox to erase skin wrinkles. That is a different, and much more lucrative kettle of fish. Because of the quest patients to look younger, Botox injections are growing by 30 to 40% a year. It’s a question of patient demand.

Here is how Marcy Tolfkoff, JD, writing in the February 6, 2006, issue of Medical Economics describes the Botox injection scene/

”One person's poison is another's passion and this is certainly true with Botox Cosmetic, a derivative of Clostritium botulinum that paralyzes muscles and keeps you from frowning or wrinkling. The craze may have started in Hollywood, and first become popular in New York and Los Angeles, but now millions of women (and some men) across the country are demanding—and getting—the smooth, young faces that Botox provides.”

“In fact, Botox injections are the most popular cosmetic procedure performed in the US. The number of minimally invasive cosmetic procedures such as Botox injections has risen dramatically, from 1.6 million injections in 2002—when Botox first received FDA approval for cosmetic use—to more than 2.9 million anatomic sites injected in 2004, according to the American Society of Plastic Surgeons. Although Botox is only approved for smoothing of the glabellar lines between the eyes, it's used off-label for multiple other cosmetic reasons such as crow's feet and laugh or frown lines.”

Botox injections, generally not covered by insurance, cost $250 to $650 per session, with an average price of about $500 per session. Therapeutic effects show in 3 to 5 days, and injections must be repeated at 4- 6 month intervals to maintain the de-wrinkling effect. Side effects and complications are rare.

Removal of Skin Lesions

Another general internist I know has gone into the skin lesion biopsy and removal business. This makes clinical, convenience, and cost effective sense.

• It makes clinical sense because aging patients, particularly those who have been exposed to the sun earlier in life, often develop basal cell or squamous cell carcinomas. If these lesions are small, primary care physicians, who has been trained to do biopsies, are perfectly capable of removing small tumors.
• It is also convenient for consumers, who may feel they don’t have the time to go to a general or plastic surgeon, particularly when the lesion can be removed while the patient is in the office.
• It makes economic sense, for the health system, the patient, and the doctors. Specialists, almost by definition, justifiably charge more for the services. Medicare pays more for removal of one skin lesion, which may take 10 minutes to perform, than for a one hour visit.

One physician who feels strongly it’s within the province and competence of primary physicians to perform minor surgical procedures is John L Pfenninger, MD. He founded the National Procedures Institute in 1989 in Michigan to reach outpatient procedural skills to primary care physicians. The Institute provides over 130 Continued Medical Education (CME) Courses at many national locations, covering a full range of office procedures. By learning procedural skills, Dr Pfenninger maintains, physicians improve continuity of care, provide comprehensive services, reduce health care costs, and enjoy an enhanced practice style.

Controversies or Opportunities for Innovation
The practices of freezing brown spots and warts with liquid nitrogen, injecting Botox to temporarily erase wrinkles and lines, and encouraging primary care physicians to remove or biopsy skin lesions, aren’t without controversy and may involve turf battles with specialists. One man’s beat may be another man’s division. Nevertheless, these practices represent windows of opportunity for some physicians and considered legitimate practices by medical authorities and , in the case of Botox, by the FDA.