Table of Content


Winter 2013, Vol. 21 No. 4

Hong Kong J. Dermatol. Venereol. (2013) 21, 167-169


"People choosing to undergo cosmetic interventions are both patients and consumers"

KM Ho 何景文

The recent local incident of disseminated mycobacterial infection after a cell-based therapy conducted in a beauty service by a medical practitioner has alerted the medical profession, Consumer Council, the beauty industry and Government of the need for closer attention to these procedures and beauty services in Hong Kong (HK).

This incident has provided an opportunity to learn and this editorial serves to share the personal view of a dermatologist with doctors who have an interest in dermatology.

Are beauty or aesthetic treatments or procedures the concern of the medical profession?

This depends on the prevailing understanding of disease, disability and health, and the duty of a doctor. According to the World Health Organisation, "disability" is an umbrella term for impairments, activity limitations and participation restrictions. "Disease" alone does not give a complete picture of the level of disability. Disability is multi-dimensional, not differentiated by the aetiology. The term cosmetic/aesthetic disability was coined to describe those who experience a negative impact to their physical and/or mental wellbeing, and interaction with their social and cultural environment and hence functioning because of physical appearance. It is clear that the medical professional will be involved in the management of people with such a need or even disability.

This view is shared by the committee appointed by the United Kingdom (UK) Government on "Review of the Regulation of Cosmetic Interventions in the UK", it "considered that people choosing to undergo cosmetic interventions are both patients and consumers. This is because they are making purchasing decisions on procedures and products that may have a significant impact on their health and wellbeing." The status that these clients are "patients" is clearly spelled out in the report.

What is the scope of services?

As there is not yet a universally agreed definition of "aesthetic medicine" or "cosmetic dermatology" which may eventually direct the professional competence and training requirement, it can be understood from the perspective of stakeholders in the field by taking a look at how they profile themselves.

In the United States (US), despite an absence of formal guidelines from the American Board of Dermatology, some dermatologists have acquired their skills in the use of botulinum toxin, fillers, and application of laser and other device-based treatment with or without full training in cutaneous surgical dermatology. A wide scope of cosmetic treatment and procedures are on offer to their clients ranging from minimal invasive procedures to operative procedures such as liposuction. The scope of service offered by these doctors can be understood as the practice of cosmetic dermatology (

Others distinguish themselves from plastic surgery by defining "aesthetic medicine" as a branch of medicine focused on satisfying the aesthetic desires and goals of patients using all medical procedures except those surgical procedures requiring an operating table and general anaesthesia. This scope is proposed by a group of doctors from a very diverse training background who offer beauty services to their clients (

In the market, an even wider scope of services are provided by non-medical personnel with an equally diverse training background in cosmetic procedures, ranging from none to certification by vocational training institutes in HK or other countries.

The scope of service is so diverse that a consensus is almost impossible, but roughly these can be grouped under the following categories:

  1. Conventional procedures that have been practised by the beauty industry for years such as "facial", massage, tattoo, ear piercing, etc.
  2. Procedures that involve injection, implantation of various substances including registered medicine or unregistered products to the skin or even into the bloodstream such as botulinum toxin, fillers, implantation of catgut, various cell therapy protocols, mesotherapy, skin whitening injection, hormones of human or animal origin.
  3. Procedures that involve external application of energy including various lasers, other light and radiofrequency devices, ultrasound, etc.
  4. Procedures that involve mechanical/chemical exfoliation of the skin such as micro-dermabrasion and chemical peeling.
  5. Other miscellaneous procedures not pertaining to the above groups such as hyperbaric oxygen, micro-needling, etc.

Judging from the perplexing range of procedures, it is understandable that there is wide variation in the levels of evidence of efficacy, adverse effects and risk, requirement of skills and clinical competence.

Are doctors at a better position in providing these services?

As cosmetic dermatology/aesthetic medicine does not fall in the scope of the mainstream medical service in the public sector, most doctors would not have been adequately exposed in this arena, regardless of their affiliated institutions or specialist training. Nevertheless, those who have had proper training in dermatology or plastic surgery or other relevant specialties will have the privilege of being able to make a correct clinical diagnosis, and will also possess a knowledge of the anatomy, mechanism, pathology of the underlying skin conditions, the scientific basis of some of these treatments and will therefore be able to select and deliver the appropriate treatment. Doctors are able to monitor treatment endpoints, adjusting relevant treatment parameters as appropriate, while monitoring for and managing any adverse effects as well as being aware of the limits of their competence. Moreover, non-dermatology medical practitioners will be equipped with a basic knowledge of infection control, risk assessment and ability to evaluate the evidence base of these therapies. Besides, the code of practice guides the profession to put the best interest of the patient first and to dissociate with any inappropriate commercial affiliation or canvassing.

The author has at times been asked "as there is not enough hands-on experience for some of these procedures, the dermatologist will not be as competent with these procedures as the operators in industry even after completion of training." The answer to this question is illustrated by the analogy of drug administration. Nobody will disagree that nurses are more proficient in drug administration (e.g. intramuscular injection, intravenous injection via the infusion pump, dilution of powder formulation, drug inventory etc). The key question is that the doctor is the bona fide person in making the diagnosis, prescribing the drug and dosage and monitoring the response to treatment. Although the learning curves for mastering these procedures can be variable, doctors trained in dermatology and plastic surgery will have a much shorter learning curve than their peers, not to mention those without basic medical training. Doctors with the relevant basic training may be able to master the operation of these device-based therapies within a few days while, at the same time, being able to monitor the results, adverse effects, and manage any unwanted effects as appropriate.

The way forward

It seems that the need for better regulation of beauty services has come on the agenda of the public administrations of other jurisdictions in the World. The UK has recently published its consultancy report in April this year. The report briefly summarised the prevailing scenario in the UK. Not surprisingly, the local scenario shares many common features with the UK. The UK report highlighted three key areas in which changes were recommended which may also be applicable to HK. The three highlighted areas are as follows:

  1. high quality care with safe products, skilled practitioners and responsible providers;
  2. an informed and empowered public to ensure people receive accurate advice, and
  3. the vulnerable are protected; and accessible redress and resolution in case of an adverse event.

As aforementioned, the Review Committee considered that people choosing to undergo cosmetic interventions are both patients and consumers as they are paying for procedures and products that may have a significant impact on their health and wellbeing.

The full report can be accessed from

Given the local incident, working groups have been set up under the Steering Committee on Review of Regulation of Private Healthcare Facilities to examine the need for a more comprehensive framework to regulate the performance of high-risk medical procedures/practices including the cosmetic/aesthetic treatment/procedures discussed above. The first working group, the Working Group on Differentiation between Medical Procedures and Beauty Services (WG), was concluded in June this year. The recommendations of the WG are yet to be announced and the way carried forward by the Steering Committee.


Update note from the Editorial Board HKJDV

The Steering Committee has since made the following seven recommendations:

  1. Cosmetic procedures involving injections should be performed by registered medical practitioners.
  2. Procedures that involve mechanical/chemical exfoliation of the skin below the epidermis should be performed by registered medical practitioners.
  3. Traditional tattooing and body-piercing are not considered as a medical procedure but that caution should be exercised when performed on high-risk areas such as the tongue or near the eyes and that all such practitioners should be well-trained and observe proper infection control measures. Consumers should be informed of the underlying risks and make informed decisions.
  4. Hyperbaric oxygen should not be done for cosmetic purposes and should be performed only by registered medical practitioners when clinically indicated.
  5. Dental bleaching should only be done by registered dentists as complications will occur if performed incorrectly or on the inappropriate client.
  6. The WG supports regulation of medical devices through legislation and to control the use of selected high-risk medical devices.
  7. It also recommends that an expert panel should be formed to advise on the risk and control of any new technologies/procedures in the cosmetic field.

The WG also supports the regulation through legislation of devices that emit different forms of energy such as lasers. The Steering Committee also supports the need for further regulation and public education of colonic irrigation.

Press releases 1 November 2013

Working Group makes recommendations on differentiating between medical procedures and beauty services: