The generational dermatology practice

Treating patients of all ages, from cradle to grave, does more than grow individual practices. Practicing generational dermatology can also help the specialty regain its rightful medical and aesthetic leadership, experts say.

"A generational practice encompasses medical, aesthetic, cosmetic, oncologic and general pediatric dermatology," says Wendy E. Roberts, M.D., who presented "Building a Generational Practice & Why You Should," earlier this year at the Generational Dermatology Symposium. She is a Rancho Mirage, Calif.-based dermatologist whose practice is approximately 60% aesthetic and 40% medical.

"It's a multi-decade approach to the evolving aging patient, using medical observations and family history," says Dr. Roberts. For example, a mother in her 40s presents with melasma that developed during her first pregnancy. "After physical examination, you determine she does have melasma, and then you ask about her children."

Perhaps the patient's 21-year-old daughter takes oral contraceptives and has noticed skin darkening on her upper lip. "You then start seeing this daughter for prejuvenation to decrease the risk of melasma," she says. The patient's other daughter could be a teenager starting to experience acne. "The patient who knows you treat hair loss also sends in her husband who is experiencing male pattern hair loss."

Dr. Roberts' generational philosophy grew out of her desire to address aging proactively, and her observation that during her 25 years in practice, academic centers failed to embrace cosmetic treatments and skincare. These circumstances allowed other practitioners to position themselves as experts in these areas. According to Dr. Roberts, "We dropped the ball. We didn't maintain leadership in those subspecialties."

Be the Expert

The situation at academic centers is changing as people realize how much science supports cosmetic surgical dermatology, says Dr. Roberts. Still, dermatologists commonly complain about losing business to medspas, and about the commoditization of their specialty. "We can't complain - we must act. Just be the expert," she says.

According to Beverly Hills, Calif.-based dermatologist Ronald L. Moy, M.D., "Other specialties are moving into injectable treatments with a 30-gauge needle or by pressing a laser button." With more general physicians branding themselves as cosmetic physicians, he says, injectable and minimally invasive treatments will become increasingly competitive.

Conversely, says Dr. Moy, hormone replacement therapy (HRT), DNA repair and nutritional supplementation are growth areas that dermatologists should consider. These patients are also his happiest. Compared to having a tighter neck or periocular skin, Dr. Moy explains, HRT can be life-changing, while nicotinamide and DNA repair creams can halt development of skin cancers.

By adopting a generational approach, says Dr. Roberts, one might acquire every member of a patient's family - by questioning not only the patient, but also inquiring about other family members, as family doctors do. "This approach brings everything from simple skincare advice to skin cancer back into your practice."

Prevention Across Generations

For Dr. Moy, generational dermatology includes a heavy focus on prevention for patients in their 20s. "The average dermatologist just says, 'wear sunscreens to prevent skin cancer and aging.' We give people supplements and creams that increase DNA repair, which prevents aging and skin cancers."

A study published in the September 2015 Journal of Drugs in Dermatology showed that a sunscreen with DNA repair enzymes performed significantly better than traditional sunscreen in reducing field cancerization of actinic keratoses and formation of cyclobutane pyrimidine dimers.¹ A phase 3 study published in the October 2015 New England Journal of Medicine showed that oral nicotinamide significantly reduced nonmelanoma skin cancer development vs placebo.²

A small study published in the March 2001 edition of The Lancet showed that DNA repair enzymes dramatically decreased formation of basal cell carcinomas in sun-damaged skin of patients with xeroderma pigmentosum. These evidence-based discoveries have not received the attention they deserve, says Dr. Moy, because they involve inexpensive off-patent ingredients.

Dr. Moy also treats many postmenopausal women whose needs have been ignored by OB/GYNs. "We see them in dermatology because so many people want to look better. And the best way to make your skin look better is to be on hormones like estrogen, DHEA and testosterone, which tighten and thicken skin."

HRT also prevents illnesses ranging from Alzheimer's and cardiovascular disease to osteoporosis, he says, and HRT can improve mood and mental health. "We should be better at preventing these medical problems. And we have the studies to do it. It's just that our education is so biased toward synthetic, patentable things because so much of our conferences is sponsored by the pharmaceutical industry."

Generational Practice ‘How-To’

Beginning or building a generational practice requires a thorough office tour and patient questionnaire, says Dr. Roberts. In her practice, highly experienced staff members show new and established patients what equipment and treatments are available and educate them about her credentials and training. "It's letting people know what services you offer, and making them come to life, not just on paper or a website."

A head-to-toe patient questionnaire includes questions like, "Are you or anyone in your family experiencing hair loss?" To go beyond the presenting complaint, Dr. Roberts sits with each cosmetic consultation patient and discusses challenges related to their skin and age. "I look for subtle signs of hair loss, earlobe laxity, eyelid laxity, neck laxity, photodamage and other signs of aging."

She then crafts a treatment plan that encompasses the patient's current and future needs. Dr. Roberts also explains to patients that relying on her aesthetic expertise will reduce costs, complications and time spent researching and trying procedures and products that may not work.

With HRT, says Dr. Moy, patients' biggest concern is cancer. However, he tells patients that most publications linking HRT with cancer were older studies involving synthetic hormones. "The use of bioidentical hormones doesn't cause cancer. I could bring out 40 articles that show no increased risk of breast cancer, for example." The same is true in prostate cancer, he adds, because many studies show that men with low testosterone are more likely to get prostate cancer than those who undergo properly administered testosterone replacement.

Challenges for Dr. Roberts include treatment costs and helping patients understand that completing a comprehensive plan takes more than one or two visits. However, she says, about 50% of cost-conscious patients overcome their reluctance after thoroughly discussing a procedure and seeing compelling before-and-after photos. She's also had patients call or meet previous patients to discuss their experiences.

"A generational practice is a decision to make a custom practice. It can be very rewarding, and it's not a mill. You will work hard in a different way. You could scurry and see five individual patients, or sit with one person and wind up treating them and their entire family. I probably make an average of about $200 extra per patient, just by asking a couple questions." The generational approach also boosts patient loyalty, she adds.

Disclosures:

Dr. Roberts is founder of the Generational Dermatology Palm Springs Symposium but reports no other relevant financial interests. Dr. Moy is scientific director for DNA EGF Renewal Cream, which markets a nicotinamide supplement and products containing DNA repair enzymes.

References:

• Carducci M, Pavone PS, De marco G, et al. Comparative Effects of Sunscreens Alone vs Sunscreens Plus DNA Repair Enzymes in Patients With Actinic Keratosis: Clinical and Molecular Findings from a 6-Month, Randomized, Clinical Study. J Drugs Dermatol. 2015;14(9):986-90.

• Chen AC, Martin AJ, Choy B, et al. A Phase 3 Randomized Trial of Nicotinamide for Skin-Cancer Chemoprevention. N Engl J Med. 2015;373(17):1618-26.

• Yarosh D, Klein J, O'connor A, Hawk J, Rafal E, Wolf P. Effect of topically applied T4 endonuclease V in liposomes on skin cancer in xeroderma pigmentosum: a randomised study. Xeroderma Pigmentosum Study Group. Lancet. 2001;357(9260):926-9.