Beyond cosmetic dermatology: Why India needs dermatosurgery (skin surgery) specialists?

Introduction  

Dermatosurgery or skin surgery is a specialized branch of medicine focusing on surgical interventions for skin-related conditions. These surgeries range from relatively simple procedures, such as mole removal, skin tags, or warts, to more complex treatments like scar revision or acne scar surgery. While the primary association of skin surgeries often lies with cosmetic enhancement, dermatosurgery plays a vital role in treating medically necessary conditions, including skin infections, benign tumors, and even skin cancer.

In India, despite the increasing demand for these services, there is a significant gap in how dermatosurgery is approached compared to developed countries. This gap stems from multiple factors, including the absence of skin cancer as a major driver for the subspecialty, economic considerations, and lack of clear specialization pathways for dermatologists.

Suitability of Specialties for Skin Surgeries

One of the key challenges in India is deciding which medical specialty is best suited for dermatosurgery. While plastic surgeons are highly skilled for cosmetic outcomes, their services tend to be expensive, and they may be an overqualified choice for minor skin surgeries. On the other hand, general surgeons may offer lower-cost options but often lack access to advanced technologies like lasers or radiofrequency devices, resulting in suboptimal cosmetic results.

The following table highlights the suitability of general surgeons, dermatologists, and plastic surgeons for dermatosurgery based on different criteria:

As illustrated in the table, there is a need for balance between the cost, access to technology, and cosmetic outcomes for skin surgeries. While plastic surgeons offer the best combination of technology and cosmetic results, dermatologists are the most suitable for smaller skin surgeries, providing a balance between affordability and patient satisfaction.

“Dermatologists are the most suitable for smaller skin surgeries, providing a balance between affordability and patient satisfaction.”

The Global Evolution of Dermatosurgery

Dermatosurgery as a subspecialty has matured in developed countries primarily due to the rise in cases of skin cancer, such as melanoma and basal cell carcinoma. In countries like the United States, Australia, and the UK, skin cancers have necessitated advanced surgical techniques, such as Mohs surgery, where dermatologists remove cancerous tissues layer by layer while preserving as much healthy tissue as possible.

For example:

• ‍United States: As per Centre for Disease Control (CDC) each year nearly 6 million people are treated for skin cancer, with dermatologists specializing in dermatosurgery being the primary care providers.
• ‍Australia: With one of the highest rates of skin cancer globally, Australia has pioneered early detection and treatment, including dermatosurgical interventions. The country sees over 3,000 skin cancer treatments done every day, driven by initiatives encouraging people to undergo regular skin checks.  
• ‍UK: In the UK it is estimated that the treatment of skin cancer costs the NHS in excess of £500m a year. The British Society for Dermatological Surgery (BSDS) highlights how the National Health Service (NHS) integrates dermatosurgery to address skin cancer cases, performing over 100,000 skin surgeries annually.

In these countries, the development of dermatosurgery as a subspecialty was supported by a combination of public awareness, technological advancements, and dedicated training programs for dermatologists.

Why India Lags Behind in Dermatosurgery?

In contrast to developed nations, dermatosurgery in India has not experienced the same level of growth. The reason largely boils down to a difference in skin cancer prevalence. The incidence of skin cancer in India is significantly lower due to the darker skin tones of the majority population, which offer natural protection against ultraviolet (UV) rays.

Comparison of Skin Cancer Prevalence:

• ‍India: The incidence of skin cancer is relatively lower in India compared to the West, constituting less than 1% of all diagnosed cancers. The prevalence of skin cancer in India is around 0.5 to 2 cases per 100,000 population, much lower compared to the 150-300 cases per 100,000 population in lighter-skinned populations in countries like Australia and the U.S.

This relatively lower skin cancer burden in India means that dermatologists have had less exposure to complex surgical cases, and hence the evolution of dermatosurgery has lagged behind.

Cosmetic Dermatology Overshadowing Medical Dermatology  

In recent years, cosmetic dermatology in India has boomed, with procedures like botox, fillers, laser hair removal, and chemical peels becoming extremely popular. The market for cosmetic dermatology is projected to grow at a CAGR of ~10%, driven by rising incomes, a growing middle class, and social media influence. This has led many dermatologists to shift their focus from medical dermatology and dermatosurgery to the more lucrative field of cosmetic treatments.

While cosmetic dermatology has gained momentum, dermatosurgery still faces challenges:

• ‍Limited Awareness: Many patients are unaware that dermatosurgery can offer solutions for conditions such as scars, cysts, or lipomas, often opting for more expensive plastic surgery solutions.
• ‍Lack of Training and Technology: While dermatologists have access to advanced technologies such as lasers and radiofrequency devices, many have not undergone specialized surgical training, unlike their counterparts in the West.

The Economic Impact and Potential for Growth  

The need for dermatosurgery in India is rising as more people seek treatment for both cosmetic and medical conditions. However, there is a major economic consideration. Plastic surgeons, while capable of performing these surgeries with great cosmetic outcomes, charge significantly higher fees compared to dermatologists.

A comparison of average procedure costs in India:

• ‍Dermatologist: A minor dermatosurgery procedure like mole removal can cost between ₹5,000 to ₹20,000, depending on the complexity and location.
• Plastic Surgeon: The same procedure can cost ₹30,000 to ₹50,000, making it unaffordable for many patients.

This economic discrepancy highlights the need for dermatologists to expand their skill sets and offer cost-effective solutions for minor skin surgeries. Additionally, many rural and semi-urban populations face a lack of access to qualified professionals for simple skin surgeries, making it essential for dermatologists to step up and fill the gap.

Dermatologists offering dermatosurgery can give the best outcomes and economic benefits to their patients:

“The economic benefit that dermatologists can offer necessitates them to enhance their skill in dermatosurgeries”

The unmet need for dermatosurgery can be understood by the unpublished data of 2019 from All India Institute of Medical Sciences (AIIMS), New Delhi. The waiting times despite running 5 minor procedural dermatology operation theatres five days a week was staggering

The Path Forward: Training and Technological Advancements  

India is currently at a crossroads where the demand for cosmetic and medical skin surgeries is growing. For dermatosurgery to become more prominent in India, a few key initiatives could drive the field forward:

• ‍Specialized Training Programs: Institutions such as the **Indian Association of Dermatologists, Venereologists, and Leprologists (IADVL)** have started offering advanced courses in dermatosurgery. Expanding these programs nationwide would help dermatologists acquire the surgical skills necessary to perform procedures traditionally handled by plastic surgeons.
• ‍Access to Technology: While technologies like lasers and radiofrequency ablation are available to most dermatologists by virtue of cosmetic dermatology, more affordable and widespread access could help dermatologists perform these procedures in smaller clinics, making skin surgeries accessible to a wider population.
• ‍Public Awareness Campaigns: Educating the public about dermatosurgery and the types of treatments available can help patients make more informed decisions. This could lead to a shift away from relying solely on plastic surgeons for minor surgeries and encourage patients to seek out dermatologists.

The current situation is ripe for dermatologists to enhance their skills in a wider range of dermatosurgeries:

1. A big percentage of population needing medically related surgeries
2. High cost of going to a cosmetic surgeon for these surgeries
3. Possible poor outcomes of choosing a general surgeon
4. Influx of other professionals in cosmetology profession, such as dental surgeons and doctors with only MBBS degrees
5. Opportunity to enhance skills that can set you apart in the competition

“Dermatosurgery has the potential for dermatologists to differentiate their careers”

Conclusion  

While India has seen a surge in cosmetic dermatology, the field of dermatosurgery remains underdeveloped. However, the growing demand for cost-effective skin surgeries, combined with the influx of new technologies, presents a unique opportunity for dermatologists to step into the role of skin surgeons. As the market for cosmetic treatments continues to grow, so too does the potential for dermatosurgery to emerge as a prominent and necessary subspecialty in India’s healthcare landscape.

By following the examples set by developed countries and focusing on the right balance between cost, technology, and patient outcomes, India can significantly enhance its dermatosurgical services, benefiting both patients and the medical community.