I f you’re interested in incorporating an office dispensing operation into your practice, but aren’t sure you’re comfortable with the concept of selling, there are still ways to make it work. You can delegate that responsibility to a staff worker, such as a nurse, aesthetician or medical assistant. But regardless of the person responsible, the success of the dispensing operation is directly related to the level of physician commitment. So, if you’re interested, then you still must assess your own personal level of commitment and interest in product selection and sales. The most successful dispensing operations are those in which the physician has a high level of interest in selecting and recommending skincare products. Patients recognize that their dermatologists not only have expertise in diagnosing and treating skin disease but also in providing routine skin care. In choosing even simple products such as cleansers, toners and moisturizers, you’re a valuable resource. If handled correctly, I believe office dispensing is in the best interest of patients for a number of reasons. As dermatologists, we know that patients often find themselves overwhelmed by the plethora of choices available at the pharmacy, health food store or at the cosmetic counter. Aggressive marketing and advertising leads to consumer confusion and frustration when expensive products are purchased but fail to deliver the promised results. I’ve been dispensing for 16 years and find it to be one of the most rewarding parts of practicing dermatology. Patients are most appreciative for good sound advice on product selection. I try to give them products that are cosmetically elegant and reasonably priced. Skincare regimens can be individualized based on skin type and pre-existing conditions such as acne, oily skin, and rosacea. I do a lot of patient education as to what products are appropriate for their skin, and probably more importantly, what products they need to avoid so as not to exacerbate existing conditions. My aesthetician works closely with me and often suggests a change in skincare regimen based on her observations of the patient’s skin while procedures are being performed. By carrying products from many different lines, we can easily make these adjustments. I prefer to hand pick the different products that I like from a number of lines. Getting to try new products is part of the fun. Here’s some general advice that I’ve found helpful for how to get started in your office. Start Simple Your main goals when choosing products are to select products that have the best therapeutic value while maintaining a favorable price point. (See “Product Selection Criteria,” on page 54 for more information.) Most dermatologists dispense only one or two lines and do so very successfully. Limiting the inventory allows you to become very familiar with the products lines available. As your formulary expands, you can choose additional items from various lines on an individual basis. The first thing you need to do is decide which types of products you’d like to offer patients. I consider four product categories to be the basics for anyone who dispenses in the office. These include: • moisturizers and sunscreens • cleansers • anti-aging products • acne preparations. These categories are essentials for a start-up dispensing operation. (When you’re ready for more advanced dispensing, you can add hair and nail products.) Here’s a closer look at each of the categories and some others you might consider. Moisturizers and Sunscreens Moisturizers should include both creams and lotions. Elderly patients tend to prefer creams over lotions due to the inherent dryness of their skin. Eye creams complete the moisturizing category. Choose sunscreens that offer broad-spectrum protection and those that are cosmetically elegant. A light, oil-free, non-comedogenic moisturizer is essential for acne patients. Cleansers Make sure to carry a gentle, bland formulation cleanser for patients with sensitive skin. Alpha hydroxy and beta hydroxy cleansers are useful for acne patients and in photoaging treatment regimens. Anti-Aging Products This is the most important and fastest changing category. Make sure to review the science behind each new product that comes to market since some over-the-counter (OTC) products make claims lacking scientific validity. As dermatologists, we’re responsible for helping our patients choose products that will provide them with therapeutic benefit. In this category, derivatives of vitamins A, C and the alpha hydroxy acids are excellent choices. The retinoids, or synthetic derivatives of vitamin A, are still the mainstay of any topical anti-aging regimen. The recent stabilization of retinol now provides us with an OTC alternative to retinoic acid. It’s important to remember that many OTC products claiming to contain retinol actually contain the derivatives retinyl palmitate or pro-vitamin A. These derivatives aren’t nearly as effective as pure retinol. There is a significant body of scientific evidence that retinol functions in the skin in a similar fashion to its derivative retinoic acid. Retinol is converted to retinoic acid in human skin. Retinol, however, is less potent than retinoic acid, and greater concentrations are necessary to achieve therapeutic benefits. The concentration of retinol varies greatly in available topical preparations. For the purposes of dispensing, you can offer products containing retinol in the range of 0.15% to 0.6%. Retinol 15 (La Roche-Posay BioMedic, France) and the Affirm retinol (Bioglan, Wayne, PA) offer cosmetically elegant products at these concentrations. Most department store brands contain concentrations of less than 0.1% and as little as 0.03%. Retinol is more easily tolerated than retinoic acid. It’s less likely to produce irritation and erythema. Accordingly, retinol is a reasonable alternative to retinoic acid for treating photoaged skin. Creams and serums with vitamin C are also popular anti-aging agents. Vitamin C is a potent antioxidant and has UV protecting properties as well. Its UV protecting properties are probably related to its anti-inflammatory effects since it has no known UV absorbing spectrum. Vitamin C is a great alternative for patients who can’t tolerate retinol or the retinoids. Cellex C (SkinCeuticals, Dallas, TX) and Active C (La Roche-Posay, France) are great choices. Alpha hydroxy acid (AHA) and beta hydroxy acid (BHA) preparations complete the anti-aging category. A recent survey of practicing dermatologists showed that 44% dispense one or more AHA product lines. The popularity of these products can be attributed to the lay press, which has heralded the benefits of the products. AHAs are available in creams, lotions and cleansers. Most products available at pharmacies or in the department stores contain 3% to 5% glycolic acid. Dispensing lines offer higher concentration products including 5% to 20% glycolic products. Because of their potential to irritate at high concentrations and low pH, the use of these products is more appropriately managed by dermatologists. What’s New In the area of cosmeceuticals some new additions for the dispensing doctor include human growth factor extracted from bioengineered skin (SkinMedica, Carlsbad, CA) and a new niacin derivative marketed as Pro-Nad (Niadyne Inc., Tucson, AZ). Preliminary studies on these products are promising and larger clinical studies are currently underway. Acne Preparations These products are more difficult to choose since there are so many options available at mass market. I seek products that don’t compete but instead provide new combinations of therapeutic agents. Oil-absorbing lotions and acne cover-up lotions with tint are popular with teens. Products containing glycolic acid and salicylic acid are beneficial for their comedolytic effect and for drying oily acne-prone skin. Specially formulated glycolic and beta hydroxy acids in solution are also beneficial. Cleansers formulated for acne-prone skin complete this category and contain either benzyol peroxide or salicylic acid. All of these represent reasonable alternatives to OTC acne treatments. Hair, Nails and Make-Up Adding hair and nail treatments and make-up constitutes more advanced dispensing. Patients often request treatment for nail problems such as onchoschizia and thin, brittle nails. Several complete nail hardening systems are available that are protein based and beneficial for brittle nails. Hair problems can also be addressed with gentle shampoos, anti-seborrheic and psoriatic preparations. Dispensing make-up is probably simpler than it seems. Choosing a full-service line such as Linda Sy Skin Care (Lafayette, CA), which I use, makes it very easy to implement. Foundations come in two hues — rose or golden tones. Three shades of each tone make up the full line. These can be easily matched to your patients’ skin tones in the office. Although many comparable products are available in department stores, patients enjoy knowing that these products are actually dermatologist developed and tested. The price point is also excellent and comparable to many large consumer brands. Responsible Dispensing Responsible dispensing begins with a discussion of products currently used and the objectives of the patient (see “Guidelines for Ethical Dispensing). Ask patients to bring their products to the office so that you can provide an initial skincare consultation. If a patient has already purchased a suitable product from a retail outlet, then suggest that your patient continue using the product and switch only if you can offer something of greater therapeutic value. Patients appreciate your concern for money already spent. After you evaluate their regimens, you can recommend ways to individualize their skincare regimens according to skin type and any dermatologic conditions that may exist. It’s often difficult to suggest change to those patients who are meticulous about their skin care. The cosmetic companies are to be commended for their continued commitment to the notion that moisturizers will erase wrinkles and that everyone should use a toner and astringent daily. A significant amount of your time as a dispensing physician will be spent not just in explaining the value of new products chosen, but in pointing out reasons to avoid some of the old ones. Discuss in detail any regimen you want your patient to follow and provide written instructions. Prepare handouts on products you frequently dispense, such as retinoids and AHAs, which you can give to patients with their products. These educational pieces are a time-saving measure and will minimize phone calls to the office. Show Your Stuff Of course, if patients can’t see the products, or they’re not displayed in an eye-pleasing way, they may never know about all the products you decide to carry. The initial set up of a dispensing operation is really quite simple. You only need the following four items: a display case, promotional information, storage space for inventory and an accounting system. An adequate display case is one of the most important components of the dispensing operation. It’s the most effective way to market your office dispensing operation. A waiting room display allows your patients to view your inventory and read promotional information. Display cases can be elaborate, but much simpler shelving or commercially available displays can function equally well. It’s also important is to have products displayed in the area where patients check out. This gives a patient an excellent opportunity to discuss products with your receptionist. Store an Adequate Inventory Having the products in-house can be a convenience for patients because they don’t need to stop somewhere else or return another time for their skincare products. So allow extra space for storing products so that you have an adequate inventory. If you don’t have the room, most companies can overnight products for quick delivery. A simple accounting system will allow you to track sales and inventory. Utilizing a superbill, much like that generated for patient services, will streamline your operation. The superbill lists all items on the formulary and their cost. After the skincare consultation, I quickly note the products that need to be dispensed on the superbill and the patient brings this list to the check-out window to purchase the products described. My billing person then enters this information into the computer for sales and inventory purposes. We use MicroPharmacy (Wethersfield, CT), which allows you to inventory, generate a sales receipt and keep a log of what patients have purchased. This is invaluable information and the system is easy to incorporate into your practice Train Your Staff It’s important to train all of your staff members to be familiar with the products you carry. Even though, as the physician, you’re most likely to assume primary responsibility for recommending products, physician extenders, such as nurses, aestheticians and front- office staff, will participate as well. The receptionist can play a key role and may be called on to answer questions about products and to recommend products as well. Therefore, it’s imperative that she understand not only the attributes of the products but the basics of skin care. She needs to be aware of any possible interaction between products. Although this training is time-consuming, it’s a crucial part of operating a successful dispensing program. I’m often asked by other doctors if it’s appropriate to provide staff members with financial incentives based on revenues generated. In my opinion, this promotes overly aggressive sales and is best avoided. Reap the Benefits You’ll certainly benefit from in-office dispensing. First, it forces you to keep current on new developments in skin care and cosmetics. Today’s consumers are very sophisticated, and the media keeps them well informed of new and exciting developments in our industry, so it’s important that you stay informed. Additionally, office dispensing is an excellent way to develop your cosmetic practice. The dialogue generated about products and skin care is a valuable entree into discussions regarding procedures for facial rejuvenation. Finally, you’ll generate revenue from a successful dispensing operation. The revenues generated vary greatly but are directly proportional to the amount of time spent discussing products. If you follow these simple steps, you won’t be the only one who will benefit from in-office dispensing. Patients also benefit from the convenience of office dispensing. They appreciate the opportunity to purchase products that aren’t available in the mass market. You can also save patients money by offering products with higher technology at reasonable prices. As dermatologists, we can also individualize skincare treatment regimens to maximize therapeutic benefits. Pre-treatment with the right cosmeceuticals before laser resurfacing or chemical peeling will enhance the outcome of the procedure. For all of these reasons, office dispensing is a value-added service for our patients. We need to ensure that as dermatologists our right to dispense from our offices is maintained. The best way we can guarantee this is to conduct ourselves in the most professional and ethical manner possible — always putting the best interests of our patients first.
How To Set up for Office-Based Dispensing
I f you’re interested in incorporating an office dispensing operation into your practice, but aren’t sure you’re comfortable with the concept of selling, there are still ways to make it work. You can delegate that responsibility to a staff worker, such as a nurse, aesthetician or medical assistant. But regardless of the person responsible, the success of the dispensing operation is directly related to the level of physician commitment. So, if you’re interested, then you still must assess your own personal level of commitment and interest in product selection and sales. The most successful dispensing operations are those in which the physician has a high level of interest in selecting and recommending skincare products. Patients recognize that their dermatologists not only have expertise in diagnosing and treating skin disease but also in providing routine skin care. In choosing even simple products such as cleansers, toners and moisturizers, you’re a valuable resource. If handled correctly, I believe office dispensing is in the best interest of patients for a number of reasons. As dermatologists, we know that patients often find themselves overwhelmed by the plethora of choices available at the pharmacy, health food store or at the cosmetic counter. Aggressive marketing and advertising leads to consumer confusion and frustration when expensive products are purchased but fail to deliver the promised results. I’ve been dispensing for 16 years and find it to be one of the most rewarding parts of practicing dermatology. Patients are most appreciative for good sound advice on product selection. I try to give them products that are cosmetically elegant and reasonably priced. Skincare regimens can be individualized based on skin type and pre-existing conditions such as acne, oily skin, and rosacea. I do a lot of patient education as to what products are appropriate for their skin, and probably more importantly, what products they need to avoid so as not to exacerbate existing conditions. My aesthetician works closely with me and often suggests a change in skincare regimen based on her observations of the patient’s skin while procedures are being performed. By carrying products from many different lines, we can easily make these adjustments. I prefer to hand pick the different products that I like from a number of lines. Getting to try new products is part of the fun. Here’s some general advice that I’ve found helpful for how to get started in your office. Start Simple Your main goals when choosing products are to select products that have the best therapeutic value while maintaining a favorable price point. (See “Product Selection Criteria,” on page 54 for more information.) Most dermatologists dispense only one or two lines and do so very successfully. Limiting the inventory allows you to become very familiar with the products lines available. As your formulary expands, you can choose additional items from various lines on an individual basis. The first thing you need to do is decide which types of products you’d like to offer patients. I consider four product categories to be the basics for anyone who dispenses in the office. These include: • moisturizers and sunscreens • cleansers • anti-aging products • acne preparations. These categories are essentials for a start-up dispensing operation. (When you’re ready for more advanced dispensing, you can add hair and nail products.) Here’s a closer look at each of the categories and some others you might consider. Moisturizers and Sunscreens Moisturizers should include both creams and lotions. Elderly patients tend to prefer creams over lotions due to the inherent dryness of their skin. Eye creams complete the moisturizing category. Choose sunscreens that offer broad-spectrum protection and those that are cosmetically elegant. A light, oil-free, non-comedogenic moisturizer is essential for acne patients. Cleansers Make sure to carry a gentle, bland formulation cleanser for patients with sensitive skin. Alpha hydroxy and beta hydroxy cleansers are useful for acne patients and in photoaging treatment regimens. Anti-Aging Products This is the most important and fastest changing category. Make sure to review the science behind each new product that comes to market since some over-the-counter (OTC) products make claims lacking scientific validity. As dermatologists, we’re responsible for helping our patients choose products that will provide them with therapeutic benefit. In this category, derivatives of vitamins A, C and the alpha hydroxy acids are excellent choices. The retinoids, or synthetic derivatives of vitamin A, are still the mainstay of any topical anti-aging regimen. The recent stabilization of retinol now provides us with an OTC alternative to retinoic acid. It’s important to remember that many OTC products claiming to contain retinol actually contain the derivatives retinyl palmitate or pro-vitamin A. These derivatives aren’t nearly as effective as pure retinol. There is a significant body of scientific evidence that retinol functions in the skin in a similar fashion to its derivative retinoic acid. Retinol is converted to retinoic acid in human skin. Retinol, however, is less potent than retinoic acid, and greater concentrations are necessary to achieve therapeutic benefits. The concentration of retinol varies greatly in available topical preparations. For the purposes of dispensing, you can offer products containing retinol in the range of 0.15% to 0.6%. Retinol 15 (La Roche-Posay BioMedic, France) and the Affirm retinol (Bioglan, Wayne, PA) offer cosmetically elegant products at these concentrations. Most department store brands contain concentrations of less than 0.1% and as little as 0.03%. Retinol is more easily tolerated than retinoic acid. It’s less likely to produce irritation and erythema. Accordingly, retinol is a reasonable alternative to retinoic acid for treating photoaged skin. Creams and serums with vitamin C are also popular anti-aging agents. Vitamin C is a potent antioxidant and has UV protecting properties as well. Its UV protecting properties are probably related to its anti-inflammatory effects since it has no known UV absorbing spectrum. Vitamin C is a great alternative for patients who can’t tolerate retinol or the retinoids. Cellex C (SkinCeuticals, Dallas, TX) and Active C (La Roche-Posay, France) are great choices. Alpha hydroxy acid (AHA) and beta hydroxy acid (BHA) preparations complete the anti-aging category. A recent survey of practicing dermatologists showed that 44% dispense one or more AHA product lines. The popularity of these products can be attributed to the lay press, which has heralded the benefits of the products. AHAs are available in creams, lotions and cleansers. Most products available at pharmacies or in the department stores contain 3% to 5% glycolic acid. Dispensing lines offer higher concentration products including 5% to 20% glycolic products. Because of their potential to irritate at high concentrations and low pH, the use of these products is more appropriately managed by dermatologists. What’s New In the area of cosmeceuticals some new additions for the dispensing doctor include human growth factor extracted from bioengineered skin (SkinMedica, Carlsbad, CA) and a new niacin derivative marketed as Pro-Nad (Niadyne Inc., Tucson, AZ). Preliminary studies on these products are promising and larger clinical studies are currently underway. Acne Preparations These products are more difficult to choose since there are so many options available at mass market. I seek products that don’t compete but instead provide new combinations of therapeutic agents. Oil-absorbing lotions and acne cover-up lotions with tint are popular with teens. Products containing glycolic acid and salicylic acid are beneficial for their comedolytic effect and for drying oily acne-prone skin. Specially formulated glycolic and beta hydroxy acids in solution are also beneficial. Cleansers formulated for acne-prone skin complete this category and contain either benzyol peroxide or salicylic acid. All of these represent reasonable alternatives to OTC acne treatments. Hair, Nails and Make-Up Adding hair and nail treatments and make-up constitutes more advanced dispensing. Patients often request treatment for nail problems such as onchoschizia and thin, brittle nails. Several complete nail hardening systems are available that are protein based and beneficial for brittle nails. Hair problems can also be addressed with gentle shampoos, anti-seborrheic and psoriatic preparations. Dispensing make-up is probably simpler than it seems. Choosing a full-service line such as Linda Sy Skin Care (Lafayette, CA), which I use, makes it very easy to implement. Foundations come in two hues — rose or golden tones. Three shades of each tone make up the full line. These can be easily matched to your patients’ skin tones in the office. Although many comparable products are available in department stores, patients enjoy knowing that these products are actually dermatologist developed and tested. The price point is also excellent and comparable to many large consumer brands. Responsible Dispensing Responsible dispensing begins with a discussion of products currently used and the objectives of the patient (see “Guidelines for Ethical Dispensing). Ask patients to bring their products to the office so that you can provide an initial skincare consultation. If a patient has already purchased a suitable product from a retail outlet, then suggest that your patient continue using the product and switch only if you can offer something of greater therapeutic value. Patients appreciate your concern for money already spent. After you evaluate their regimens, you can recommend ways to individualize their skincare regimens according to skin type and any dermatologic conditions that may exist. It’s often difficult to suggest change to those patients who are meticulous about their skin care. The cosmetic companies are to be commended for their continued commitment to the notion that moisturizers will erase wrinkles and that everyone should use a toner and astringent daily. A significant amount of your time as a dispensing physician will be spent not just in explaining the value of new products chosen, but in pointing out reasons to avoid some of the old ones. Discuss in detail any regimen you want your patient to follow and provide written instructions. Prepare handouts on products you frequently dispense, such as retinoids and AHAs, which you can give to patients with their products. These educational pieces are a time-saving measure and will minimize phone calls to the office. Show Your Stuff Of course, if patients can’t see the products, or they’re not displayed in an eye-pleasing way, they may never know about all the products you decide to carry. The initial set up of a dispensing operation is really quite simple. You only need the following four items: a display case, promotional information, storage space for inventory and an accounting system. An adequate display case is one of the most important components of the dispensing operation. It’s the most effective way to market your office dispensing operation. A waiting room display allows your patients to view your inventory and read promotional information. Display cases can be elaborate, but much simpler shelving or commercially available displays can function equally well. It’s also important is to have products displayed in the area where patients check out. This gives a patient an excellent opportunity to discuss products with your receptionist. Store an Adequate Inventory Having the products in-house can be a convenience for patients because they don’t need to stop somewhere else or return another time for their skincare products. So allow extra space for storing products so that you have an adequate inventory. If you don’t have the room, most companies can overnight products for quick delivery. A simple accounting system will allow you to track sales and inventory. Utilizing a superbill, much like that generated for patient services, will streamline your operation. The superbill lists all items on the formulary and their cost. After the skincare consultation, I quickly note the products that need to be dispensed on the superbill and the patient brings this list to the check-out window to purchase the products described. My billing person then enters this information into the computer for sales and inventory purposes. We use MicroPharmacy (Wethersfield, CT), which allows you to inventory, generate a sales receipt and keep a log of what patients have purchased. This is invaluable information and the system is easy to incorporate into your practice Train Your Staff It’s important to train all of your staff members to be familiar with the products you carry. Even though, as the physician, you’re most likely to assume primary responsibility for recommending products, physician extenders, such as nurses, aestheticians and front- office staff, will participate as well. The receptionist can play a key role and may be called on to answer questions about products and to recommend products as well. Therefore, it’s imperative that she understand not only the attributes of the products but the basics of skin care. She needs to be aware of any possible interaction between products. Although this training is time-consuming, it’s a crucial part of operating a successful dispensing program. I’m often asked by other doctors if it’s appropriate to provide staff members with financial incentives based on revenues generated. In my opinion, this promotes overly aggressive sales and is best avoided. Reap the Benefits You’ll certainly benefit from in-office dispensing. First, it forces you to keep current on new developments in skin care and cosmetics. Today’s consumers are very sophisticated, and the media keeps them well informed of new and exciting developments in our industry, so it’s important that you stay informed. Additionally, office dispensing is an excellent way to develop your cosmetic practice. The dialogue generated about products and skin care is a valuable entree into discussions regarding procedures for facial rejuvenation. Finally, you’ll generate revenue from a successful dispensing operation. The revenues generated vary greatly but are directly proportional to the amount of time spent discussing products. If you follow these simple steps, you won’t be the only one who will benefit from in-office dispensing. Patients also benefit from the convenience of office dispensing. They appreciate the opportunity to purchase products that aren’t available in the mass market. You can also save patients money by offering products with higher technology at reasonable prices. As dermatologists, we can also individualize skincare treatment regimens to maximize therapeutic benefits. Pre-treatment with the right cosmeceuticals before laser resurfacing or chemical peeling will enhance the outcome of the procedure. For all of these reasons, office dispensing is a value-added service for our patients. We need to ensure that as dermatologists our right to dispense from our offices is maintained. The best way we can guarantee this is to conduct ourselves in the most professional and ethical manner possible — always putting the best interests of our patients first.
I f you’re interested in incorporating an office dispensing operation into your practice, but aren’t sure you’re comfortable with the concept of selling, there are still ways to make it work. You can delegate that responsibility to a staff worker, such as a nurse, aesthetician or medical assistant. But regardless of the person responsible, the success of the dispensing operation is directly related to the level of physician commitment. So, if you’re interested, then you still must assess your own personal level of commitment and interest in product selection and sales. The most successful dispensing operations are those in which the physician has a high level of interest in selecting and recommending skincare products. Patients recognize that their dermatologists not only have expertise in diagnosing and treating skin disease but also in providing routine skin care. In choosing even simple products such as cleansers, toners and moisturizers, you’re a valuable resource. If handled correctly, I believe office dispensing is in the best interest of patients for a number of reasons. As dermatologists, we know that patients often find themselves overwhelmed by the plethora of choices available at the pharmacy, health food store or at the cosmetic counter. Aggressive marketing and advertising leads to consumer confusion and frustration when expensive products are purchased but fail to deliver the promised results. I’ve been dispensing for 16 years and find it to be one of the most rewarding parts of practicing dermatology. Patients are most appreciative for good sound advice on product selection. I try to give them products that are cosmetically elegant and reasonably priced. Skincare regimens can be individualized based on skin type and pre-existing conditions such as acne, oily skin, and rosacea. I do a lot of patient education as to what products are appropriate for their skin, and probably more importantly, what products they need to avoid so as not to exacerbate existing conditions. My aesthetician works closely with me and often suggests a change in skincare regimen based on her observations of the patient’s skin while procedures are being performed. By carrying products from many different lines, we can easily make these adjustments. I prefer to hand pick the different products that I like from a number of lines. Getting to try new products is part of the fun. Here’s some general advice that I’ve found helpful for how to get started in your office. Start Simple Your main goals when choosing products are to select products that have the best therapeutic value while maintaining a favorable price point. (See “Product Selection Criteria,” on page 54 for more information.) Most dermatologists dispense only one or two lines and do so very successfully. Limiting the inventory allows you to become very familiar with the products lines available. As your formulary expands, you can choose additional items from various lines on an individual basis. The first thing you need to do is decide which types of products you’d like to offer patients. I consider four product categories to be the basics for anyone who dispenses in the office. These include: • moisturizers and sunscreens • cleansers • anti-aging products • acne preparations. These categories are essentials for a start-up dispensing operation. (When you’re ready for more advanced dispensing, you can add hair and nail products.) Here’s a closer look at each of the categories and some others you might consider. Moisturizers and Sunscreens Moisturizers should include both creams and lotions. Elderly patients tend to prefer creams over lotions due to the inherent dryness of their skin. Eye creams complete the moisturizing category. Choose sunscreens that offer broad-spectrum protection and those that are cosmetically elegant. A light, oil-free, non-comedogenic moisturizer is essential for acne patients. Cleansers Make sure to carry a gentle, bland formulation cleanser for patients with sensitive skin. Alpha hydroxy and beta hydroxy cleansers are useful for acne patients and in photoaging treatment regimens. Anti-Aging Products This is the most important and fastest changing category. Make sure to review the science behind each new product that comes to market since some over-the-counter (OTC) products make claims lacking scientific validity. As dermatologists, we’re responsible for helping our patients choose products that will provide them with therapeutic benefit. In this category, derivatives of vitamins A, C and the alpha hydroxy acids are excellent choices. The retinoids, or synthetic derivatives of vitamin A, are still the mainstay of any topical anti-aging regimen. The recent stabilization of retinol now provides us with an OTC alternative to retinoic acid. It’s important to remember that many OTC products claiming to contain retinol actually contain the derivatives retinyl palmitate or pro-vitamin A. These derivatives aren’t nearly as effective as pure retinol. There is a significant body of scientific evidence that retinol functions in the skin in a similar fashion to its derivative retinoic acid. Retinol is converted to retinoic acid in human skin. Retinol, however, is less potent than retinoic acid, and greater concentrations are necessary to achieve therapeutic benefits. The concentration of retinol varies greatly in available topical preparations. For the purposes of dispensing, you can offer products containing retinol in the range of 0.15% to 0.6%. Retinol 15 (La Roche-Posay BioMedic, France) and the Affirm retinol (Bioglan, Wayne, PA) offer cosmetically elegant products at these concentrations. Most department store brands contain concentrations of less than 0.1% and as little as 0.03%. Retinol is more easily tolerated than retinoic acid. It’s less likely to produce irritation and erythema. Accordingly, retinol is a reasonable alternative to retinoic acid for treating photoaged skin. Creams and serums with vitamin C are also popular anti-aging agents. Vitamin C is a potent antioxidant and has UV protecting properties as well. Its UV protecting properties are probably related to its anti-inflammatory effects since it has no known UV absorbing spectrum. Vitamin C is a great alternative for patients who can’t tolerate retinol or the retinoids. Cellex C (SkinCeuticals, Dallas, TX) and Active C (La Roche-Posay, France) are great choices. Alpha hydroxy acid (AHA) and beta hydroxy acid (BHA) preparations complete the anti-aging category. A recent survey of practicing dermatologists showed that 44% dispense one or more AHA product lines. The popularity of these products can be attributed to the lay press, which has heralded the benefits of the products. AHAs are available in creams, lotions and cleansers. Most products available at pharmacies or in the department stores contain 3% to 5% glycolic acid. Dispensing lines offer higher concentration products including 5% to 20% glycolic products. Because of their potential to irritate at high concentrations and low pH, the use of these products is more appropriately managed by dermatologists. What’s New In the area of cosmeceuticals some new additions for the dispensing doctor include human growth factor extracted from bioengineered skin (SkinMedica, Carlsbad, CA) and a new niacin derivative marketed as Pro-Nad (Niadyne Inc., Tucson, AZ). Preliminary studies on these products are promising and larger clinical studies are currently underway. Acne Preparations These products are more difficult to choose since there are so many options available at mass market. I seek products that don’t compete but instead provide new combinations of therapeutic agents. Oil-absorbing lotions and acne cover-up lotions with tint are popular with teens. Products containing glycolic acid and salicylic acid are beneficial for their comedolytic effect and for drying oily acne-prone skin. Specially formulated glycolic and beta hydroxy acids in solution are also beneficial. Cleansers formulated for acne-prone skin complete this category and contain either benzyol peroxide or salicylic acid. All of these represent reasonable alternatives to OTC acne treatments. Hair, Nails and Make-Up Adding hair and nail treatments and make-up constitutes more advanced dispensing. Patients often request treatment for nail problems such as onchoschizia and thin, brittle nails. Several complete nail hardening systems are available that are protein based and beneficial for brittle nails. Hair problems can also be addressed with gentle shampoos, anti-seborrheic and psoriatic preparations. Dispensing make-up is probably simpler than it seems. Choosing a full-service line such as Linda Sy Skin Care (Lafayette, CA), which I use, makes it very easy to implement. Foundations come in two hues — rose or golden tones. Three shades of each tone make up the full line. These can be easily matched to your patients’ skin tones in the office. Although many comparable products are available in department stores, patients enjoy knowing that these products are actually dermatologist developed and tested. The price point is also excellent and comparable to many large consumer brands. Responsible Dispensing Responsible dispensing begins with a discussion of products currently used and the objectives of the patient (see “Guidelines for Ethical Dispensing). Ask patients to bring their products to the office so that you can provide an initial skincare consultation. If a patient has already purchased a suitable product from a retail outlet, then suggest that your patient continue using the product and switch only if you can offer something of greater therapeutic value. Patients appreciate your concern for money already spent. After you evaluate their regimens, you can recommend ways to individualize their skincare regimens according to skin type and any dermatologic conditions that may exist. It’s often difficult to suggest change to those patients who are meticulous about their skin care. The cosmetic companies are to be commended for their continued commitment to the notion that moisturizers will erase wrinkles and that everyone should use a toner and astringent daily. A significant amount of your time as a dispensing physician will be spent not just in explaining the value of new products chosen, but in pointing out reasons to avoid some of the old ones. Discuss in detail any regimen you want your patient to follow and provide written instructions. Prepare handouts on products you frequently dispense, such as retinoids and AHAs, which you can give to patients with their products. These educational pieces are a time-saving measure and will minimize phone calls to the office. Show Your Stuff Of course, if patients can’t see the products, or they’re not displayed in an eye-pleasing way, they may never know about all the products you decide to carry. The initial set up of a dispensing operation is really quite simple. You only need the following four items: a display case, promotional information, storage space for inventory and an accounting system. An adequate display case is one of the most important components of the dispensing operation. It’s the most effective way to market your office dispensing operation. A waiting room display allows your patients to view your inventory and read promotional information. Display cases can be elaborate, but much simpler shelving or commercially available displays can function equally well. It’s also important is to have products displayed in the area where patients check out. This gives a patient an excellent opportunity to discuss products with your receptionist. Store an Adequate Inventory Having the products in-house can be a convenience for patients because they don’t need to stop somewhere else or return another time for their skincare products. So allow extra space for storing products so that you have an adequate inventory. If you don’t have the room, most companies can overnight products for quick delivery. A simple accounting system will allow you to track sales and inventory. Utilizing a superbill, much like that generated for patient services, will streamline your operation. The superbill lists all items on the formulary and their cost. After the skincare consultation, I quickly note the products that need to be dispensed on the superbill and the patient brings this list to the check-out window to purchase the products described. My billing person then enters this information into the computer for sales and inventory purposes. We use MicroPharmacy (Wethersfield, CT), which allows you to inventory, generate a sales receipt and keep a log of what patients have purchased. This is invaluable information and the system is easy to incorporate into your practice Train Your Staff It’s important to train all of your staff members to be familiar with the products you carry. Even though, as the physician, you’re most likely to assume primary responsibility for recommending products, physician extenders, such as nurses, aestheticians and front- office staff, will participate as well. The receptionist can play a key role and may be called on to answer questions about products and to recommend products as well. Therefore, it’s imperative that she understand not only the attributes of the products but the basics of skin care. She needs to be aware of any possible interaction between products. Although this training is time-consuming, it’s a crucial part of operating a successful dispensing program. I’m often asked by other doctors if it’s appropriate to provide staff members with financial incentives based on revenues generated. In my opinion, this promotes overly aggressive sales and is best avoided. Reap the Benefits You’ll certainly benefit from in-office dispensing. First, it forces you to keep current on new developments in skin care and cosmetics. Today’s consumers are very sophisticated, and the media keeps them well informed of new and exciting developments in our industry, so it’s important that you stay informed. Additionally, office dispensing is an excellent way to develop your cosmetic practice. The dialogue generated about products and skin care is a valuable entree into discussions regarding procedures for facial rejuvenation. Finally, you’ll generate revenue from a successful dispensing operation. The revenues generated vary greatly but are directly proportional to the amount of time spent discussing products. If you follow these simple steps, you won’t be the only one who will benefit from in-office dispensing. Patients also benefit from the convenience of office dispensing. They appreciate the opportunity to purchase products that aren’t available in the mass market. You can also save patients money by offering products with higher technology at reasonable prices. As dermatologists, we can also individualize skincare treatment regimens to maximize therapeutic benefits. Pre-treatment with the right cosmeceuticals before laser resurfacing or chemical peeling will enhance the outcome of the procedure. For all of these reasons, office dispensing is a value-added service for our patients. We need to ensure that as dermatologists our right to dispense from our offices is maintained. The best way we can guarantee this is to conduct ourselves in the most professional and ethical manner possible — always putting the best interests of our patients first.
