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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 13  |  Issue : 3  |  Page : 95-98

Where are we in cosmetics and esthetics practices in educational clinics in Turkey?


1 Department of Dermatology, University of Health Sciences, Şişli Etfal Training and Research Hospital, Istanbul, Turkey
2 Doku Medical Centre, Medeniyet University, Göztepe Training and Research Hospital, Istanbul, Turkey
3 Department of Dermatology, Medeniyet University, Göztepe Training and Research Hospital, Istanbul, Turkey

Date of Submission10-Apr-2019
Date of Decision16-May-2019
Date of Acceptance16-May-2019
Date of Web Publication17-Oct-2019

Correspondence Address:
Dr. Ezgi Ozkur
Department of Dermatology, University of Health Sciences, Şişli Etfal Training and Research Hospital, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TJD.TJD_6_19

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  Abstract 

Objective: Cosmetic dermatology has recently gained importance with the recent increase in demand. The aim of this study is to identify cosmetic dermatology training in Turkey and to assess instructors' attitudes toward cosmetic dermatology training during residency and current cosmetic dermatology practices. Methods: This is a cross-sectional questionnaire study conducted with instructors to investigate the practice of cosmetics dermatology, the technical equipments, number of patients, and their ideas in the clinics that provide dermatology specialty education in Turkey. Results: At least one cosmetic procedure was found to be performed in 69% of the clinics that participated in the study (n = 55), and no cosmetic procedure was performed in 31% of the clinics. The mean number of application was 13.2 ± 12.3 weekly in the clinics that performed cosmetics procedure. The most common procedures were botulinum toxin injection with 63.6% (n = 35), chemical peeling with 60% (n = 33), and platelet-rich plasma with 60% (n = 33), respectively. The most common laser application was neodymium-doped yttrium aluminum garnet (28/55). The mean time spent for cosmetic procedures was 1–5 h weekly in the clinics which performed cosmetic procedures. Seventy-six percent (n = 42) of the participants felt inadequate for performing cosmetics procedures, and 95% (n = 52) reported that cosmetic dermatology education was required. Conclusions: Both theoretical and practical education must be given in educational clinics, and the infrastructure must be created, and the educational schedule must be standardized.

Keywords: Cosmetics, dermatology, education


How to cite this article:
Ozkur E, Kaynak E, Gürel MS. Where are we in cosmetics and esthetics practices in educational clinics in Turkey?. Turk J Dermatol 2019;13:95-8

How to cite this URL:
Ozkur E, Kaynak E, Gürel MS. Where are we in cosmetics and esthetics practices in educational clinics in Turkey?. Turk J Dermatol [serial online] 2019 [cited 2019 Nov 20];13:95-8. Available from: http://www.tjdonline.org/text.asp?2019/13/3/95/269500




  Introduction Top


Specialty education is an organized education program with theoretical and practice studies of residents. Medical faculty graduates can study dermatology in Turkey after passing the medical specialty examination (MSE) which is held twice annually, and dermatology specialty education lasts 4 years in university hospitals, and training and research hospitals hospitals affiliated to the Turkish Ministry of Health. There has recently been an increasing interest on dermatology, and the mean MSE scores required for entering the dermatology specialty are higher than all other specialties. One of the reasons of this is the increased demand for esthetic and cosmetic procedures.

Dermatologists have contributed significantly to the evolution of cosmetic and esthetics dermatology including laser treatments, dermabrasion, botulinum toxin, chemical peeling, hair transplantation, and soft-tissue augmentation. Aspects of cosmetic dermatology include the maintenance of healthy skin, the prevention and treatment of skin aging and photodamage, and rejuvenation procedures. To continue as leaders in the safe performance of cosmetic dermatology procedures, future dermatologists must be properly trained. Moreover, dermatologists who received no cosmetic education are less preferred in private hospitals and clinics, and they may feel unqualified. Furthermore, if a training gap exists, this may adversely affect patient safety.

Moreover, there are many dermatological diseases which could be treated with cosmetic procedures. These indications are laser procedures for rosacea, infectious disorders (mostly papillomavirus lesions), the removal of hairs and tattoos, vitiligo, vascular lesions, cutaneous scarring, some skin tumors, postlesional hyperpigmentation and melasma, mesotherapy or platelet-rich plasma (PRP) for androgenetic alopecia, botulinum toxin injection for hyperhidrosis, as well as chemical peeling, Dermapen, and dermaroller treatments for acne scars and hyperpigmentation.[1],[2],[3],[4] So that, cosmetic dermatology must not be apart from traditional dermatology education but should be a part of it. In the present study, we aimed to investigate the cosmetic dermatology training during residency and the current cosmetic dermatology practices in the clinics which provide dermatology specialty education in Turkey.


  Methods Top


The present research is a cross-sectional descriptive questionnaire study. A questionnaire was prepared to investigate the cosmetic dermatology education and practices in dermatology education clinics including the detailed information about the cosmetic procedures performed in the clinics, the number of patients presenting for cosmetic procedures, technical equipments, the weekly time spent for cosmetic dermatology, cosmetic dermatology education, and the personal competency. The questionnaire was performed on February 2019 to the instructors who participated to general council meeting about education in dermatology of the Turkish Society of Dermatology. Participants who did not work in clinics which provide dermatology specialty education were excluded, and only one instructor was included from each clinic. The opinions of the participants were measured with their yes–no responses to the questions whether cosmetic procedures were performed (botulinum toxin, filler, etc.) in the clinic, personal competency, and whether the cosmetic education was required. The number of patients applying for these procedures and the monthly number of cosmetic procedures performed in the clinic were measured as the numerical data.

Data were analyzed using IBM SPSS 15.0 for Windows v.21.0. (IBM Corp., Armonk, NY). Number and percentage were given for descriptive statistics and categorical variables; and the mean, standard deviation, minimum, and maximum were given for numerical variables. The ethics board approval was granted.


  Results Top


The study included the 75% (n = 55) of the total 73 clinics that provide dermatology specialty education in Turkey. We found that 76% (n = 42) of the participant clinics were from university hospitals, and 24% (n = 13) were from education and training hospitals. Sixty-nine percent (n = 38) of participants reported that cosmetic procedures were performed in their clinics; however, 31% (n = 17) of participants reported that no cosmetic procedure was performed in their clinics. The mean number of patients applying for cosmetic procedure was detected as 13.2 ± 12.3 in the cosmetic procedure performing clinics.

The percentages of cosmetic procedures performed among all participated training clinics are demonstrated in [Figure 1]. The most common procedures were botulinum toxin in 63.6% (n = 35), chemical peeling in 60% (n = 33), and PRP in 60% (n = 33), respectively. The least common procedures were the thread lift and pulsed dye laser procedures which were only performed in a total of 6 clinics (10.9%). The mean number of applications to these clinics is demonstrated in [Table 1]. Neodymium-doped yttrium aluminum garnet (Nd:YAG) laser device was detected in 28 clinics, carbon dioxide in 10 clinics, erbium YAG in 8 clinics, pulsed dye in 6 clinics, diode in 2 clinics, KTP in 2 clinics, alexandrite in 1 clinic, and Q-switched nd:YAG device was detected in 1 clinic.
Figure 1: The percentages of cosmetic procedures performed among all participated training clinics in Turkey

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Table 1: The weekly number of patients applying to education clinics which perform cosmetic procedure in Turkey in accordance with the cosmetic procedure type

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We found that 90% (n = 34) of the cosmetic procedure performing clinics obtained the patient consent forms from their patients. Twenty-two percent (n = 12) of the participants claimed that they never participated to cosmetic education courses, meeting, or congress. A mean weekly time spent for these procedures was <5 h in 68% (n = 26) of cosmetic procedure performing education clinics. Seventy-six (n = 42) of the participants felt themselves unqualified for performing cosmetic procedures, and 95% (n = 52) of the participants suggested that cosmetic dermatology education was required in dermatology education [Table 2].
Table 2: Opinions of the participants about the cosmetic dermatology practice, competency, and education

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  Discussion Top


In recent times, there has been an increasing demand for noninvasive cosmetic procedures worldwide. So-called noninvasive cosmetic procedures are botulinum toxin injection, filler, PRP, mesotherapy, dermaroller, dermapen, thread lift, and laser methods. A survey with 561 primary care physicians identified dermatologists as the most qualified specialists to inject botulinum toxin and fillers and to perform laser procedures.[5] Since the procedures are performed on the skin, and on subcutaneous tissues, dermatologists are the primary professionals in practice, also in the determination of the doses, monitoring of the effect, and in the management of the complications compared with the other branches. Şavk reported the European Union of Medical Specialists (UEMS) as the most authorized and effective international politic organ for all medical practices including the medical specialty education in Europe, in her article in 2012.[6] UEMS evaluates the cosmetic dermatology within the scope of the dermatology branch. Furthermore, dermatocosmetology is described in the “important learning area” for the residents in the Core Learning Curriculum in Turkey.

There are 73 education clinics which provide dermatology specialty education in Turkey; yet, there is no standardized curriculum for cosmetic dermatology education, and there are differences between the clinics regarding the technical equipment, practitioner or auxiliary staff, and education hours. Residents evaluated the importance of cosmetics education as 4.33 in 5 score system in a cross-sectional questionnaire study of Yılmaz and Akkaya[7] conducted with 67 residents in 2006 in Turkey. In the same study, they reported the adequacy of cosmetic dermatology education as 1.83 (mean) out of 5 in their own clinics. Cengiz et al.[2] conducted a survey with 121 Turkish residents in 2014, and they found that 73 (60.3%) residents could not learn the cosmetic procedures in their clinics. In line with these studies, a study by Freiman et al. was conducted with 48 dermatology residents across Canada and reported that residents were least satisfied with cosmetic dermatology training in their residency program (2.7 of 5.0).[8]

The importance of cosmetic dermatology in dermatology specialty has also been increasing worldwide. Interestingly, Kiafar et al. reported that professors and program directors predicted residents' first priority would be practicing cosmetic dermatology and 41 (60.3%) of them agreed or strongly agreed that residents' desire to learn more about cosmetic procedures resulted in their decreased interest in learning medical procedures.[9] Although there is a concern in the questionnaire studies that cosmetic dermatology will be more popular than the medical dermatology, the requirement for adequate education was suggested in both foreign studies, and in our study.[10],[11] Almost all studies conducted with education clinics and residents on this topic are reported from the USA. The most important reason is that cosmetic dermatology has a significant market share in the USA. A questionnaire study was conducted in 2013 with the administrators of the clinics providing dermatology specialty education in the USA and authors reported that 63% (20 participants of 32) of the administrators suggested that cosmetic dermatology education must be “compulsory.”[12] The same study reported that theoretical education on liposuction, laser, filler, botulinum toxin injection, chemical peeling, dermabrasion, scar revision, and sclerotherapy was given in 67% of the clinics. Champlain et al. reported in their study conducted in the USA in 2018 that 90% of dermatology residents indicated that practice was more important than theoretical education in cosmetic dermatology education. The same study reported that 244 residents of 268 (91%) had the opportunity to perform hands-on cosmetic procedures by themselves.[13]

The most frequently performed cosmetic procedure was detected as the botulinum toxin injection (63.6%) among all clinics that participated in our study. The study of Kirby et al. reported 95% of 73 dermatology residents had the opportunity to perform botulinum toxin injection in their clinics in the USA. The practice rates for the laser procedures was reported as 97%, for filler was 85%, for chemical peeling was 85%, and the rate for sclerotherapy was 71% in the study.[12] In another study conducted with 3rd-year dermatology residents from the University of Texas Medical Faculty, authors reported that 75 (63.6%) trainees felt comfortable performing botulinum toxin injections, 55 (47%) were comfortable performing laser surgery, 47 (39.8%) were comfortable performing chemical peels, and 37 (31.4%) were also comfortable performing fillers.[14] On the other hand, Plee et al. reported that only 3% of residents had a cosmetic dermatology education during residency, and authors underlined the need for greater focus cosmetic dermatology in France between 2005 and 2010.[15]

The most frequently used laser device in our study was the nd:YAG laser which was used in nearly half of the clinics. Bauer et al. reported that the most frequently used laser was pulsed dye (79%), second Q-switched nd:YAG (58%), and the third most frequently used was the fractional carbon dioxide (38%) in their study which they conducted with dermatology education clinics in the USA.[16] The comparison of the education clinics in Turkey with the education clinics in the USA showed that both the cosmetic procedures, and the diversity of the laser devices, and practices were inadequate in Turkey. This difference may attribute to the lack of financial resources, inadequate number of personnel, and problems in pricing. In addition, we found that 76% (n = 42) of the instructors felt themselves unqualified, and the number of patients applying to the clinics was low in general. In this step, “training of the instructor” must also be emphasized. Dermatology Post Specialty Education Board, that serves within the body of the Turkish Society of Dermatology, organized the first “Practical Cosmetics and Medical Esthetics Course on Anatomy and Fresh Cadaver for Dermatologists” this year. The increase of the number of such courses will also increase the number of the practices of the cosmetic procedures in the clinics.

The limitations of the study were that we could not reach all education clinics, and no face-to-face interview was performed with the participants during the questionnaire procedure. In addition, it is unclear whether the resident is included in the process even if the procedures are performed in the clinics.


  Conclusions Top


The present study demonstrates the cosmetic dermatology practices, technical equipments, number of patients, and cosmetic dermatology education in the clinics providing dermatology specialty education in Turkey. Cosmetic dermatology seems to be a popular branch of dermatology which shows rapid progress and which needs to be a part of specialty education. Cosmetic dermatology education should not overshadow the medical dermatology education, however must be complementary. Cosmetic dermatology education must be so well-organized that residents must feel qualified and confident enough to perform the procedures in their professional life. Residents who cannot be provided such conditions may visit other clinics with external rotations for a limited time to provide this education or procedural competency can be achieved including with certain number of hands-on courses offered at local, regional, and national meetings for residents. There is a need for a cosmetic dermatology curriculum program, as well as a common curriculum program for traditional dermatology education, which could be practiced in each clinic that will standardize the cosmetic dermatology education and practice in specialty education.

Acknowledgments

This study was performed within the scope of the Turkish Society of Dermatology. We acknowledge the Turkish Society of Dermatology, to the president Emel Erdal Çalıkoǧlu for her help and to the resident representatives Ozan Erdem and Çaǧdaş Akaslan in delivering and collecting the questionnaires.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Cengiz FP, Kemeriz F, Emiroglu N, Meydan MC. Dermatology Residents' Opinions: Problems and Proposals of Their Solutions in Residency Training. Turk J Dermatol 2014;8:88.  Back to cited text no. 2
    
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Melo DF, de Mattos Barreto T, Plata GT, Araujo LR, Tortelly VD. Excellent response to mesotherapy as adjunctive treatment in male androgenetic alopecia. J Cosmet Dermatol 2019. doi: doi.org/10.1111/jocd.12983.  Back to cited text no. 3
    
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Saadawi AN, Esawy AM, Kandeel AH, El-Sayed W. Microneedling by dermapen and glycolic acid peel for the treatment of acne scars: Comparative study. J Cosmet Dermatol 2019;18:107-14.  Back to cited text no. 4
    
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Ibrahimi OA, Bangash H, Green L, Alam M, Armstrong AW, Eisen DB. Perceptions of expertise in cutaneous surgery and cosmetic procedures: What primary care physicians think. Dermatol Surg 2012;38:1645-51.  Back to cited text no. 5
    
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Savk E. Avrupa'da Dermatoveneroloji egitimi/dermatovenereology training in Europe. Turk Dermatol Derg 2012;6:123.  Back to cited text no. 6
    
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Yılmaz S, Akkaya VB. Problems and Proposals of Their Solutions in Dermatology Residency Training: A Survey of Residents' Opinions in Turkey. Arch Turk Dermatol Venerol Turk 2009;43:1.  Back to cited text no. 7
    
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Freiman A, Barzilai DA, Barankin B, Natsheh A, Shear NH. National appraisal of dermatology residency training: A Canadian study. Arch Dermatol 2005;141:1100-4.  Back to cited text no. 8
    
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Kiafar B, Nahidi Y, Morovatdar N, Maleki M, Teimoorian M, Ghazvini K, et al. A national survey: Desire of dermatology residents to train in cosmetic dermatology and its association with learning medical dermatology. Acta Med Iran 2018;56:591-7.  Back to cited text no. 9
    
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Schleichert R, Hostetler SG, Zirwas M. The perceived influence of cosmetic dermatology on dermatology resident education. J Am Acad Dermatol 2010;63:352-3.  Back to cited text no. 10
    
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Duffy D, Torok H, Keeling J, Rendon MI. Surveying cosmetic procedural residency training: Are we short-changing tomorrow's dermatologists? A preliminary report. Cosmet Dermatol Cedar Knolls 2008;21:506-11.  Back to cited text no. 11
    
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Kirby JS, Adgerson CN, Anderson BE. A survey of dermatology resident education in cosmetic procedures. J Am Acad Dermatol 2013;68:e23-8.  Back to cited text no. 12
    
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Champlain A, Reserva J, Webb K, Griffin D, Moy L, Joyce C, et al. Cosmetic dermatology training during residency: Outcomes of a resident-reported survey. Dermatol Surg 2018;44:1216-9.  Back to cited text no. 13
    
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Group A, Philips R, Kelly E. Cosmetic dermatology training in residency: Results of a survey from the residents' perspective. Dermatol Surg 2012;38:1975-80.  Back to cited text no. 14
    
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Plee J, Barbe C, Richard MA, Dreno B, Bernard P. Survey of post-graduate training for dermatology and venereology residents in France (2005-2010). Ann Dermatol Venereol 2013;140:259-65.  Back to cited text no. 15
    
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