RI’s medical spa industry riled by new guidance on who can give Botox

The Rhode Island Department of Health issued new guidelines for medical spas, requiring patients to be assessed by a licensed practitioner before receiving services.
The guidelines were issued in response to concerns about the safety of procedures like Botox and fillers being performed by unqualified individuals.
Legislation has been introduced to allow registered nurses to continue providing these services under the supervision of a physician or nurse practitioner.

PROVIDENCE – Can you guess which piece of legislation drew the most people to the State House earlier this week to make impassioned pleas for legislative help preserving their livelihoods – and their wrinkle-free foreheads?

If you guessed a bill to remove a wrinkle-causing worry from the brows of the estheticians who inject soft tissue fillers and Botox into the faces of clients at the growing number of “medical spas” across the state, you would have been right.

As the “medical spa” industry grows, the concerns raised by some full-fledged dermatologists led the Rhode Island Department of Health to issue guidelines last summer on “who can inject what” into customers in the state.

That, in turn, led Rep. Jacquelyn Baginski, D-Cranston, to introduce a bill to make sure the practitioners in this arm of the beauty industry – many of them nurses – can continue what they have been doing uninterrupted.

She was responding to the concerns of medical spa operators and their clients, including Alexandra McSparren, who sent the House Committee on Health & Human Services a letter that said:

“The [Rhode Island Department of Health] is limiting access to the services I have been receiving from my current aesthetic practitioner. I have been told I will no longer be able to receive Botox, PRF and micro needling from my nurse practitioner and aesthetician.”

“I do not want to lose my right to choose my provider,” she wrote, And “I do not want to be forced to drive to neighboring states to seek these services.”

“Aesthetic medicine is not just about appearance,” added George Hatfield of Westerly, in his own letter. “It boosts confidence, supports mental well-being, and allows individuals to feel their best.”

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What change did the state make for medical spas?

At minimum, the new RIDOH guidance requires that any patient “receiving any service or procedure in a medical spa or IV therapy business … [must] first be assessed by a Rhode Island licensed practitioner,” which in this context means: “a physician, physician assistant and/or certified nurse practitioner.”

What led to the change?

Department of Health spokesman Joseph Wendelken told The Journal that there’s been a “proliferation” of two new health care businesses: medical spas and intravenous (IV) therapy businesses. Services at these businesses, Wendelken said, are advertised as “minimal risk” and are seen more as spa treatments than medical procedures.

But a RIDOH review determined that many of these businesses were operating without proper health care facility licensure and, in some cases, allowing people to perform procedures “that were not within their scope of practice” – putting clients, they said, at a “higher risk” of complications.

What kind of complications?

In his own letter to the legislative committee, state Health Director Jerome Larkin cited the risks of getting “cosmetic injections” of soft tissue fillers and neurotoxins, such as Botox, in the face, “where blood vessels and nerves are much more superficial than in the deltoid and gluteal regions where nurses and other healthcare professionals are trained to inject vaccines and medications intramuscularly.”

He said studies demonstrate that complication rates for filler and Botox injections are “higher when performed by non-physicians versus physicians.”

They include: “Skin necrosis, scarring, disfigurement, nerve damage, muscle paralysis, blindness, and even stroke.”

Even more basically, Larkin said: “Allowing unlicensed people with only 20 hours of training (versus three to six years of training for dermatologists and plastic surgeons) to perform these procedures is unsafe.”

During its review of what is happening in Rhode Island, the Health Department found that, in some instances, a dermatologist or plastic surgeon is the owner of one of these spas. In others, it is an esthetician, while others are owned by unlicensed investors.

“Some medical spas may try to circumvent the necessity of a physical assessment through the use of standing orders” on how to diagnose and assess patients, but this “is considered unprofessional conduct and can result in disciplinary action on one’s license,” RIDOH said.

What does the bill do?

RIDOH’s 12-page “Guidance Document Regarding the Operation of Medical Spas and Intravenous (IV) Therapy Businesses” sent shudders through the Rhode Island beauty industry.

The Baginski bill, co-sponsored by Reps. David Bennett of Warwick, a nurse, and Stephen Casey of Woonsocket, an EMT, says, in part, that nothing in the law shall be construed to prohibit:

“A registered nurse from … providing cosmetic injections such as soft tissue fillers and neurotoxins, intravenous fluids, vitamin injections, laser hair removal, intense pulsed light, laser skin resurfacing, microneedling, laser vein removal, scelerotherapy, and radiofrequency,” as long as they are under the “supervision” of a physician, nurse practitioner or an “advanced practice registered nurse” who does not necessarily have to be on site.

Supervision is not required for “a licensed esthetician to practice esthetics,” a licensed electrologist to engage in laser hair removal, or a licensed tattoo artist from engaging in “the practice of tattoo artistry, including inkless stretch mark revision, permanent makeup artistry, microblading, and saline tattoo removal.”

Close to 40 people signed up to speak and dozens more sent letters to the Health and Human Services Committee.

With few exceptions, they pleaded for relief from what the health department liaison Neil Hytinen described as a codification – not a change – in existing law.

In their letters, many of the clients, both men and women, insisted the treatments are necessary for their “confidence and self-esteem,” and letting the spas do their thing, unimpeded, keeps the services affordable.

As Hatfield of Westerly wrote: “The RIDOH is limiting access to the services I have been receiving from my current aesthetic practitioner. I have been told I will no longer be able to receive Botox, dermal filler, laser hair removal, microneedling, and platelet-rich plasma.”

“As someone who has personally benefited from aesthetic treatments performed by highly skilled NPs and RNs, I can attest to the exceptional level of care, expertise, and safety they provide,” Hatfield continued. “Restrictive regulations that prevent qualified NPs and RNs from practicing in this field [will] only limit access to safe, affordable, and effective treatments.”

From outside Rhode Island came the voice of Ben Conn, the director of product for the Columbus, Ohio-based Monarch Aesthetic Services.

“Are doctors going to start operating lasers instead of training skilled nurses on their use? Are doctors going to stay in office and perform these tasks instead of going away on vacations? The answer is always no,” he wrote.

By contrast, “a professional, licensed nurse or esthetician gets into the field to provide quality of care, education and to help patients age more gracefully and happily,” Conn said.

“It would be a shame if a few who are jealous attempted to take that away from those that earned their right to practice.”

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