Don’t Let Beauty Blind You: Unveiling Clinical Diagnoses During Cosmetic Dermatology Practice

J Clin Aesthet Dermatol. 2024;17(11–12 Suppl 1):S30–S33.

by Miguel A. Aristizabal, MD; Tara Soto, PA-C; Leila Tolaymat, MD; and Alison J. Bruce, MB ChB

All authors are with the Department of Dermatology at Mayo Clinic Florida in Jacksonville, Florida.

FUNDING: No funding was provided for this study. 

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

ABSTRACT: There has been a notable rise in the prevalence of cosmetic dermatology services worldwide, involving a diverse range of providers. Patients presenting with cosmetic concerns should be thoroughly assessed and require meticulous attention because subtle, unexpected clinical cues might necessitate the application of dermatologic expertise. In this study, we present a case series involving patients who sought cosmetic care at an academic cosmetic dermatology center, revealing subsequent diagnoses of significant medical conditions. This underscores the critical importance of comprehensive training and substantial clinical exposure for practitioners in the highly nuanced field of dermatology. Keywords: Dermatology, cosmetic dermatology, aesthetic medicine, hyperpigmentation, melanoma, laser resurfacing, acne, basal cell carcinoma, osteoma cutis.

Introduction

In recent years, cosmetic dermatology procedures have experienced a notable surge in attention. Cosmetic noninvasive and minimally invasive procedures are prevalent in the media and social media platforms. According to a survey on dermatologic procedures conducted by the American Society for Dermatologic Surgery (ASDS), member dermatologists of the ASDS performed over 10.3 million cosmetic treatments in 2019, reflecting a 14-percent increase compared to the results of 2018.¹ Moreover, the procedural statistics from the American Society of Plastic Surgeons (ASPS) for 2023 revealed a total of 23,672,269 cosmetic minimally invasive procedures performed by those surveyed, with a notable 70-percent increase in the use of injectables.²

This trend has witnessed a proliferation of practitioners offering aesthetic services, often in the medical spa setting—an industry that recently has grown nearly six fold. However, only four percent of these facilities report a dermatologist as the owner or collaborating physician.³ Interestingly, complication rates in cosmetic procedures have increased,⁴ raising questions about potential under or misdiagnosis in these scenarios.

Oftentimes, dermatologists emerge as the preferred source for basic information and procedure selection among consumers.⁵ In the same line, previous evidence has highlighted that consumers might exhibit a preference for physicians over other types of practitioners when it comes to the selection of cosmetic providers, a trend that might be influenced by mass media.⁶

Commonly, during cosmetic practice, providers often focus on the patient’s primary cosmetic concerns. However, trained clinicians have the ability to explore additional symptoms and exercise medical suspicion to identify potential signs of disease. A trained eye can be instrumental in drawing conclusions and uncovering additional medical entities that might not be easily detected.

The following clinical cases presented primarily for cosmetic reasons to the cosmetic center of an academic dermatology department. Following a review of their medical history and a comprehensive examination, several underlying diseases were detected.

Methods

The study was deemed exempt by the Mayo Clinic institutional review board. A retrospective chart review was conducted on patients who were diagnosed with clinical entities while receiving care at the Mayo Clinic Florida’s Cosmetic Center from January 2018 to January 2024. Nine cases were identified.

Results

Case 1. A 58-year-old man was referred for laser treatment of a lesion on the nasal tip that had been present for approximately one year, primarily for aesthetic reasons. The patient’s past medical history included nonmelanoma skin cancer and actinic keratoses. In addition to intrinsic and extrinsic signs of skin aging, clinical examination revealed a 2mm dark violaceous papule on the nasal tip. Considering the extensive dermatoheliosis and the clinical characteristics of the lesion, a punch biopsy was recommended and subsequently performed, rather than proceeding with laser treatment as requested. Results indicated a malignant melanoma, lentigo maligna type, Clark level III, with a Breslow depth of 1.3mm, not ulcerated, and not mitotically active. The tumor was classified as Stage pTIIa. The patient underwent wide local excision with local flap reconstruction and sentinel lymph node biopsy, which returned negative results. He has since been regularly monitored by dermatology without any recurrence to date (Figure 1).

Case 2. A 68-year-old woman was undergoing intense pulsed light (IPL) therapy for the treatment of solar lentigines and dyschromia. Her past medical history included malignant melanoma on one extremity more than 20 years ago. Interestingly, one hyperpigmented patch over the left cheek proved to be treatment resistant. The resistant lesion was a 1.7 x 1.5cm asymmetric, nonhomogeneous, and irregularly shaped brown patch located over the left zygoma. Due to the clinical appearance and suboptimal response to IPL, a shave biopsy was performed, revealing a malignant melanoma in situ of the lentigo maligna type. She subsequently underwent Mohs micrographic surgery (MMS) followed by repair with a rotation flap, without complications. The patient is under regular monitoring, and no recurrence has been encountered (Figure 2).

Case 3. A 56-year-old man with a family history of malignant melanoma and significant sun exposure presented with concerns of facial skin aging. During consultation, a thorough clinical examination revealed significant dermatoheliosis. Additionally, a pigmented lesion was noted incidentally on his right shoulder; however, the patient was uncertain about how long the lesion had been present. Further examination showed an irregularly pigmented, asymmetric brown macule measuring 1.2cm in diameter, which prompted a shave biopsy. The histopathologic report confirmed a malignant melanoma in situ, lentigo maligna type. Subsequently, the patient underwent wide local excision without complications and is currently undergoing regular follow-up
(Figure 3).

Case 4. A 58-year-old man presented with concerns of facial skin aging. He had a past medical history of multiple actinic keratoses and nonmelanoma skin cancers. Clinical examination revealed dermatoheliosis and erythematous scaly macules, particularly at the hairline, along with a few scattered hyperpigmented brown macules on the forehead and cheeks, including one on the mid-forehead. Given the subtle pigmentary changes and signs of skin aging, the patient underwent treatment with one session each of dual wavelength 1470nm/2940nm laser, IPL, and CO₂ laser without complications, in addition to treatment for the actinic keratoses with cryotherapy and photodynamic therapy. 

However, a hyperpigmented lesion on the forehead persisted and remained almost unchanged after the initial approach, prompting a punch biopsy. Histopathology revealed a malignant melanoma, nodular, Clark level III, Breslow depth 2.2mm, ulcerated, and mitotically active (<1mm²/per high-powered field), with a T-classification of pT3b and Stage IIIc. Extension PET-CT did not show hypermetabolic metastatic disease. He subsequently underwent wide local excision with local flap closure and lymph node biopsy, which turned out negative. Surgical pathology revealed peripheral melanoma in situ, necessitating pembrolizumab treatment and six scouting biopsies, which showed melanoma in situ inferiorly. A second surgical intervention with MMS and closure was successfully performed. The patient continues to follow-up with dermatology (Figure 4).

Case 5. A 43-year-old woman was referred to the cosmetic center for the removal of acrochordons in the axillae and along waistline. Her past medical history was unremarkable. During physical examination a 6mm irregularly pigmented melanocytic papule with a white hue under dermoscopy was noted on the lateral aspect of the right upper arm, raising concern for malignant melanoma. Biopsy revealed a malignant melanoma, superficial spreading type invasive to Clark’s level IV, with a Breslow’s depth of 0.9mm². Both the radial growth phase and vertical growth phase (epithelioid cell type) were present, and the mitotic rate was 1/mm². The patient underwent treatment with wide local excision and lymph node biopsy, which yielded negative results. She continues to follow up with dermatology for further monitoring (Figure 5).

Case 6. A 65-year-old woman, showing signs of photoaging inquired about laser resurfacing options. Her medical history included facial actinic keratosis, lumbar radiculopathy, Sjogren syndrome, and a benign thyroid nodule. During physical examination, a 6.5mm erythematous, irregular, depressed plaque was detected over the left eyebrow, with the patient unable to specify its duration. A shave biopsy revealed a nodular basal cell carcinoma. Treatment involved MMS with advancement flap repair, which proceeded without complications. Currently, she is undergoing IPL treatments for dyschromia and remains under follow-up (Figure 6).

Case 7. A 65-year-old woman presented with concerns of facial skin aging and the presence of asymptomatic, discrete facial lesions, for which she was desiring ablative laser. The patient had a past medical history of sarcoidosis and was undergoing treatment with methotrexate and prednisone. Upon physical examination, several euchromatic, monomorphic, discrete, firm papules affecting the bilateral cheeks and chin were noted. Due to the atypical presentation of the lesions and the patient’s medical history, a punch biopsy was performed, revealing osteoma cutis. She was treated with a neuromodulator for facial rhytides, and excision of the lesions was suggested, although full face fractionated ablative laser was not recommended, despite the patient’s initial request. She continues to follow up with both the rheumatology and dermatology departments. (Figure 7).

Case 8. A 25-year-old woman presented complaining of facial papules. She was initially treated with hydroquinone at a local spa for presumed hyperpigmentation. The patient had no relevant past medical history and was otherwise healthy. Physical examination showed comedones, inflammatory papules, and scattered violaceous macules involving the forehead, temples, cheeks, and chin. A diagnosis of cystic acne was made, hydroquinone was discontinued, and topical and systemic retinoids, along with an appropriate skincare routine, were suggested. The patient exhibited significant improvement after four months of treatment and continues to follow up
(Figure 8).

Case 9. A 59-year-old woman was undergoing treatment for facial telangiectatic vessels associated with erythematotelangiectatic rosacea. Initial examination revealed dermatoheliosis with linear telangiectasias over the nose. The patient’s past medical history included chronic allergic (follicular) conjunctivitis, for which she had received treatment with topical corticosteroids with partial benefit. This prompted a referral to the cosmetic center for IPL as an alternative last resort. During examination, an unusual and profuse conjunctival redness was noted bilaterally. In addition to the IPL treatment, a referral for conjunctival biopsy was made. Histopathology revealed chronic conjunctivitis with rare non-necrotizing granulomas, raising suspicion for sarcoidosis. Subsequently, the patient was diagnosed with ocular sarcoidosis by ophthalmology and initiated on directed therapy. IPL treatment was discontinued, and she continues to follow up with rheumatology and ophthalmology (Figure 9).

Discussion

The clinical cases described underscore the importance of thorough patient assessment beyond cosmetic concerns. Timely diagnosis is crucial in preventing adverse outcomes and avoiding delays in treatment or inappropriate therapeutic interventions. We advocate for the necessity of a comprehensive medical history and clinical examination in every cosmetic consultation, despite the heightened focus on cosmetic-driven concerns.

Lately, an escalation in the number and type of providers within the cosmetic arena has become apparent. This phenomenon might serve as a potential remedy for addressing the physician shortage.⁷ Nonetheless, it is imperative to recognize that this uptick could potentially result in an unintended increase in misdiagnosis or underdiagnosis rates, thereby posing a risk to overall clinical outcomes. Previous reports have indicated differences in the diagnostic accuracy of skin cancer between dermatologists and other providers with the latter showing lower accuracy in diagnosing melanoma compared to the former.⁸ This emphasizes the importance of the depth and duration of medical training in enhancing diagnostic capabilities, particularly in the nuanced field of dermatology.

Clinical training and experience constitute invaluable tools that clinicians should not underestimate. We hypothesize that a robust medical training is integral in increasing clinicians’ diagnostic accuracy; with over 7 to 10 years of training and more than 10,000 hours of patient care, dermatologists are well-equipped to detect challenging and unusual conditions.⁹ This places them in a pivotal role in the cosmetic setting and offers significant leadership opportunities within collaborative, multifaceted teams.

Academic cosmetic centers provide an ideal training environment where trainees can be exposed to a wide range of techniques and procedures. This helps fill the gap in resident trainee education by providing a holistic approach to cosmetics, meeting the demands of patients seeking cosmetic treatment.^10,11 Cultivating a collegiate environment within private, community, or academic practices is crucial for optimizing patient care.

Conclusion

Cosmetic dermatology is an expanding field that attracts providers from diverse backgrounds. Oftentimes, subtle clinical cues might go overlooked in the dynamic, fast-paced environment of cosmetics. Dermatologists, with their extensive training, have the potential to assume a leadership role in patient care, leveraging their expertise to enhance clinical acumen across a wider spectrum and instilling confidence among team members with varying levels of expertise. Furthermore, this specialized training serves as a valuable asset, aiding in the prevention of oversight of significant diseases during physical examinations. It underscores the pivotal role of dermatologists as key figures and potential leaders in the ongoing aesthetic revolution.

References:

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