Dermatologists, the medical experts on skin, have been battling a dramatic rise in skin-cancer rates in recent years. More than a million cases are diagnosed annually; cases of melanoma, the most lethal form of skin cancer, jumped from 47,700 in 2000 to nearly 69,000 last year. With such increases, many people are now visiting a dermatologist regularly. But not all. In an ideal world, everyone would visit a dermatologist to have a baseline skin exam, says Bruce Brod, a Lancaster, Pa., dermatologist who chairs a number of committees for the American Academy of Dermatology, the field s professional organization. But, he adds, that s difficult since there are only about 10,000 dermatologists in the U.S., serving 309 million people.

Many patients are looking to dermatologists for help with less press-ing matters. Last year there were more than 6 million nonsurgical cosmetic procedures performed in the U.S. such as injections of Botox and fillers like Restylane to help with wrinkles, and laser treatments to encourage new skin growth, remove hair or eradicate blemishes. Dermatologists perform the bulk of these services. No wonder new patients had to wait an average of 34 days for an appointment.

Nonsurgical cosmetic procedures are a booming business: Last year Americans spent $4.5 billion on them. Primary-care physicians, ob-gyns and even dentists have begun performing procedures like laser hair removal and skin resurfacing. Everyone wants to be a dermatologist, says Sabra Sullivan, a Jackson, Miss., dermatologist. But while dermatologists spend three to five years after medical school learning about the skin, others may have taken little more than a weekend of classes.

A growing number of procedures are available outside a doctor s office. Med spas combine the ambience of a day spa with the services of a medical staff that can provide Botox, filler, laser and other treatments. They operate under the supervision of a physician but there s no guarantee this doctor has any dermatology training. In 2002 there were 45 med spas in the U.S.; by 2009 there were 2,500. With spotty regulation of the industry, dermatologists worry about patient safety. But Hannelore Leavy, founder of the Day Spa Association and the International Medical Spa Association, says many kinds of physicians can become experts in these treatments.

Laser treatments, Botox injections and chemical peels seem like simple procedures. But things can go wrong with even the simplest of them. In 2004, when then-20-year-old Alexandra Gelfand was home from college on a break, her mother bought her a facial treatment. Though Gelfand was unaware of it at the time, the facialist gave her a glycolic acid peel and left the chemical on for too long. The next day, Gelfand says, her face was bloody, swollen and oozing. It healed only after months of treatments by a dermatologist, she says, and she still has small scars.

Dermatologist and DermTV.com founder Neal Schultz, who treated Gelfand for her injuries, says he has seen patients arrive in his office with severe burns from laser treatments and droopy eyelids from poorly injected Botox. Consumers should research their physicians to ensure that they are either board-certified dermatologists or plastic surgeons and to make certain that the doctor, not an assistant, will be performing complex procedures, says Stephen Schleicher, a Hazleton, Pa. based dermatologist. The quality of the person rendering the procedure is incredibly important, he says.

It's easy to think that with a little Botox here, some Restylane there and a bit of clean up with a laser, you ll be looking like your teenage self again. But it s hard to reverse the clock, says New York City dermatologist Darrell Rigel. We can slow it down and, in some cases, move it back a little, but that s it. That s because as we age, our skin loses its elasticity and begins to sag.

We produce less collagen, so the face loses its fullness. We develop wrinkles from repetitive muscle movement, and the skin develops spots and dilated blood vessels.

Dermatologists say they can take five or so years off your appearance: Botox can help relax frown lines, and fillers can restore some tautness and roundness to your skin. In addition, laser treatments can remove spots, while more powerful lasers can promote the production of collagen, and with it a more youthful appearance. But much more than that may not be desirable, says Sullivan, the Mississippi dermatologist. No one is going to look like they are 18 when they are 60, she says. Ultimately, you want people to say that you look good and rested.

Dermatologists often experiment with new treatments. In part that s because some of the diseases they treat are too rare to support the large drug trials required for FDA approval, says Jeffrey Benabio, a San Diego dermatologist who blogs at TheDermBlog.com. Such creative use of drugs is legal; once a drug is approved by the FDA, physicians can administer it as they see fit. For example, Botox Cosmetic is approved to alleviate furrows between the eyebrows. Using it anywhere else is considered off-label and these days that includes a large proportion of its cosmetic uses, says Schultz.

When injected, botulinum toxin widely known by its market-leading brand name, Botox can migrate to other body parts, leading to complications, according to the FDA. Advocacy group Public Citizen says it found 18 reports of severe problems resulting from cosmetic use of botulinum toxin over nine years. Last year the FDA added a warning, highlighting the product s ability to spread. A spokesperson for Botox Cosmetic manufacturer Allergan says that during 20 years of use, there have been few reports of its spreading.

With all the hype surrounding nonsurgical cosmetic procedures, it s easy to think these are quick, painless affairs that will change your appearance with no downtime. But even lasers designed for age spots the removal of which often entails a short recovery period can cause bruising that lasts up to a week. And skin-resurfacing treatments, in which a layer of skin is removed with a laser to encourage growth of new skin cells, can leave a patient s face oozing and crusted over for as long as 10 days.

Some treatments, like those using fractional lasers to address tiny wrinkles, have a shorter recovery time. But quick treatments might not work for much else, no matter what the ads say. What concerns me is people who have significant sun spots and wrinkles putting a lot of faith in these ads, says Benabio. It s doing them a disservice. Those patients need more powerful lasers essentially, more-expensive procedures with longer recovery periods, he says. Schultz adds that patients should ask lots of questions and research the doctor performing the procedure. For their part, doctors should underpromise and overdeliver, he says.

Antiaging skin-care products brought in $1.6 billion in 2008.

These creams and lotions may have some value, but none has demonstrated effectiveness in enough peer-reviewed studies to claim to cure anything or gain FDA approval. Some dermatologists say there s evidence that antioxidants can help improve the skin s appearance and boost the effectiveness of sunscreen, while others note that retinol, which is basically vitamin A, has shown some promise as well.

Doctors work with companies to develop and test these products and in some cases even to get their name featured on the label. It s easy to do; contract firms create a lotion, and doctors use their name to market it. Schultz, for one, has his own line of skin-care products and stands by it, saying he s not about to put out an inferior product. My name and my credibility are much more important than any extra money, he says. But Benabio sees the trend as potentially detrimental to the credibility of physicians. It makes all dermatologists look a little worse,
he says. We are too willing to do things for mercenary reasons.

The official word from the American Academy of Dermatology is that there s no such thing as safe sun exposure, which is why the organization recommends wearing sunscreen every time you go outside. Pennsylvania dermatologist Brod adds that people should avoid direct sunlight between 10 a.m. and 3 p.m. and wear UV-protective clothing. You have to play it smart when it comes to sun exposure, he says.

But not everyone is on board. Michael Holick, an endocrinologist and professor at the Boston University Medical Center, and the author of The Vitamin D Solution, is one of a number of doctors and researchers who think such an anti-sun position is a big mistake. Our bodies produce vitamin D when we are exposed to sunlight; Holick says high levels of vitamin D gained from even moderate exposure have been shown to boost the immune system, increase bone density and decrease the risk of hypertension. And, he says, vitamin D deficiencies can have a hand in ailments like chronic fatigue, depression, heart disease, cancer and diabetes which outweigh any increased risk of skin cancer from moderate sun exposure. Dermatologists have to moderate their position on this, he says.

Becky Helman was always afraid to get a facial. She has sensitive skin and rosacea, a condition that causes redness. But Helman, a 55-year-old Maryland real estate agent, has to look good for her clients. So after medication from her dermatologist failed to work, she tried a facial treatment at Blu Water Day Spa in Kensington, Md. They gave her a collagen mask and an antioxidant treatment, then used LEDs to help the skin absorb the antioxidant. She was surprised at the result. The texture of my skin changed. It glows. The fine lines are gone, Helman says.

Plain old spas offer some beneficial treatments dermatologists rarely perform, like microdermabrasion, which encourages new cell growth, and facials, which cleanse pores and give skin a brighter, fresher look.
But Rigel, the dermatologist from New York, says these treatments can only do so much, as they only work on the top layer of skin. Sullivan adds that as long as consumers are aware of the limitations of these treatments, they should enjoy themselves. It s nice to be pampered, she says.

Dermatologists are in high demand, and it s only expected to get worse. About 300 new dermatologists enter the field every year just enough to replace those who are retiring and it s unlikely that many new residency positions will open up, says Jack Resneck Jr., an associate professor of dermatology and health policy at the University of California, San Francisco. There is a lot of pent-up demand, he says. As baby boomers get older, they are likely to need more care, and with upwards of 30 million people soon to be insured, thanks to health care reform, many people will be able to see a dermatologist who may not have before.

But technology may help some dermatologists reach out to more patients. Schleicher, who practices in Pennsylvania, uses digital images to diagnose inmates at 30 prisons in his state. This technique works particularly well for dermatology, a field in which most problems can be diagnosed visually, and it s supported by the American Academy of Dermatology. Schleicher says he can diagnose 95 percent of the problems
he runs across from a photograph, and he follows up with a teleconference with the patient and their physician. It s fantastic, he says.