AAMSSA Report: Risky Business – The Challenges, Risks and Legalities Involved in the Practice of Aesthetic Medicine in Salons and Spas


AAMSSA President, Dr Debbie Norval uncovers the challenges, risks and legalities involved in the practice of aesthetic medicine in salons and spas

We’ve all experienced a typical doctor’s rooms, with the stern receptionist, plastic chairsand long wait while reading outdated magazines. It’s clinical and intimidating, with the anxiety inducing waft of medical disinfectant in the air. Compare this to a spa. Now that’s a different story altogether!  The word alone sounds soothing and relaxing.  The spa evokes images of candles, beautiful music, warmth and pampering, friendly helpful staff and luxurious treatments.

So it’s not surprising that the concept of combining beauty treatments with medical aesthetic procedures is so tempting. Many business and spa owners are lured by the demand and profitability of medical treatments, yet are not fully informed about the medical, legal and regulatory risks involved. And while this practice is not illegal, AAMSSA has many concerns about doctors practicing medicine in a non-clinical setting such as a spa or salon.

Who/What is AAMSSA?

AAMSSA (Aesthetic and Anti-Aging Society of South Africa) is a SAMA (South African Medical Association) affiliated scientific society that is mandated to enhance education, regulation and the safe and legitimate practice of Aesthetic and Anti-Aging Medicine in South Africa. And because aesthetic medicine is a medical discipline, it is for the safety of our patients that AAMSSA strongly encourages our doctors to work in a clinical setting, rather than in salons or spas.

Practicing medicine in non-clinical premises

Doctors in South Africa are regulated by the rules and ethical guidelines set by the Health Professions Act and the HPCSA (Health Professions Council of South Africa) The HPCSA Ethical Guidelines clearly state that unless it is an emergency, a medical act must be performed under proper conditions and appropriate surroundings. When aesthetic medical procedures are performed in a salon or spa, it is done so on premises that are non-clinical, unregulated and lacking an aseptic environment.

Lack of medical supervision

Most medical aesthetic treatments require supervision by a medical doctor who should be physically present on the premises. Unfortunately, many doctors working in salons and spas are only there for a few hours a week, if that. Some medi-spas have a doctor who supports their treatments and writes scripts, but doesn’t even visit the premises.  The non-medical staff are therefore left unsupervised most of the time. It’s suffice to say that a doctor’s “support” or a once-a-week visit is not acceptable or safe practice.

“Public perception is that because the treatment is in a spa-like setting, the procedures must thus be safe and low risk”

Initial assessment by the doctor

Many patients aren’t aware that when they see a therapist for any medical aesthetic treatment, they must first have had a doctor’s consultation. Sadly, patients often don’t even know who the prescribing doctor is, which is of particular concern should a complication occur. Additionally, supervising doctors should evaluate each patient before treatment, obtain written informed consent for every procedure, prescribe treatments and remain actively involved in the course of treatment. A doctor needs to be readily available to deal with adverse events, even if the actual procedure is delegated to a therapist or nurse.

A false sense of security

Public perception is that because the treatment is in a spa-like setting, the procedures must thus be safe and low risk. But it must be noted that medical aesthetic treatments carry the same risk as any medical procedure. Complications from medical treatments can be very serious, and include infection and sepsis, bleeding and haematoma formation, vascular occlusion, tissue necrosis and blindness. Some medical treatments also carry the risk of burns, scarring, keloid formation, nodules and granuloma formation. Furthermore, any injectable treatment has the risk of allergy, hypersensitivity reactions, anaphylactic shock and even death. It is therefore foolish to believe that just because the treatment is performed in a salon or spa that nothing will go wrong.

“Practising medicine in salons, spas and hairdressers does nothing to advance the safety, credibility and standards of aesthetic medicine”

The Pseudo-Science of the beauty industry

Many salon treatments claim to rejuvenate the skin but aren’t supported by scientific evidence or research. Phrases such as “clinically proven” or “dermatologist approved” have little true meaning. In the beauty industry, products range from mango pulp to snail slime to retinol and antioxidants. While many beauty industry products are excellent, there is no rule that they have to be scientifically proven to work.

This is very different to a medical practice where doctors are regulated by the HPCSA, which states that doctors are not allowed to “perform or direct procedures to be performed on a patient that are neither indicated nor scientific, or that have been shown to be ineffective, harmful or inappropriate through evidence-based review”.

Services in any medical practice have to be evidence-based. This means clinically proven to be effective through scientific studies and research, as well as being published in the medical literature. Any deviation from this normal practice of modern medicine reduces professionalism and undermines trust in aesthetic medicine by the public, along with the rest of the medical fraternity.

Inadequately trained personnel

When working in a medical environment, aestheticians require the correct qualification and designation. Unfortunately, many beauty therapists working in a medical spa are acting outside of their scope of practice. Although a therapist might feel capable of performing medical procedures involving needles or ablative lasers, if anything had to go wrong, the supervising doctor will be charged with aiding and abetting in the unauthorised practice of medicine.

They may also then be disciplined, sued, fined, lose their medical licence or even jailed.  As for the therapist, they could be criminally prosecuted. For this reason, therapists working in aesthetic medicine under the supervision of a doctor ideally require a Somatology degree or an Advanced Diploma in Dermal Aesthetics.

Consumer Confusion

There are concerns that if aesthetic medicine is practiced in a spa or salon, it will be marketed like a pedicure, so consumers may be led to believe that being injected, lasered and resurfaced needs no more thought than changing one’s nail colour. Consequently, the merging of medical procedures with beauty therapies results in the trivialisation and commercialisation of aesthetic medicine, with consumers becoming confused over the medical nature of the procedures, are not fully informed of the risks, and often don’t even know who is responsible for their procedure.

Recently, there has been a significant clamp down on medi-spa’s in the United States. The Texas Senate Bill 2366 was passed in March 2019, which requires medical spas to post a notice informing consumers of who may perform which procedures, while providing the Consumer Protection Division’s contact information to all clients.

De-Medicalisation of Aesthetic Medicine

Internationally, the UIME (International Union of Aesthetic Medicine) and locally, AAMSSA, continually strive to promote the science and safety of aesthetic medicine. Practicing medicine in salons, spas and shops in malls does nothing to advance the safety, credibility and standards of aesthetic medicine. In the Netherlands, aesthetic medicine has recently been granted medical specialty status in order to counteract the lack of regulation in the industry.

HPCSA guidelines regarding working in a non-clinical setting

Although regarded as an “undesirable practice” by the HPCSA, it is not illegal in South Africa for a doctor to work in a salon or spa. However, the HPCSA states that the doctor would have to strictly comply with all laws, rules andguidelines that need to be in place to practice medicine in a non-clinical setting.

Some examples of these rules are:

  • A doctor may not share rooms with a person who is not a doctor and registered in terms of the Health Professions Act.
  • The doctors consulting room must have a separate entrance, reception and seating area, where patients are separated from the public. Furthermore, the consulting room must be a separate walled off room for the privacy of patients, the preservation of confidentiality, and the safe keeping of records.
  • Most importantly, medical hygiene must be strictly adhered to with a washing station, personal protective equipment (such as gloves and gowns), a medical waste and sharps disposal protocol, and adequate sterilisation equipment.
  • There additionally needs to be a blood-borne pathogen and exposure control plan, incidents and needle stick injury protocol, as well as resuscitation equipment such as emergency drugs, oxygen and a defibrillator.

And that’s not all…

In addition to the abovementioned regulations for working in a spa/salon, there are other key rules and guidelines that are just as important, such as:

  • The doctor may not pay or receive any commission, or share any income with the salon/spa – and must also manage their own appointments and invoicing while using their own separate payment system. The doctor may not order medical grade cosmeceutical products for the salon/spa.
  • HPCSA has strict rules regarding canvassing, touting or unprofessional advertising. The salon may not advertise on behalf of the doctor, nor mention scheduled medicine trade names, Class III Medical Devices or In Vitro Diagnostics , as well as price lists or discounts in their advertising, marketing or social media.
  • Confidentiality is also vitally important in medicine, so medical records must be kept secure. Moreover, salon and spa staff are not allowed access to the medical records without express written consent from the patient. Medical notes should be kept at the doctor’s practice to protect patients’ confidentiality.
  • If in doubt (and according to the HPCSA Ethical booklet on Business Practice), a doctor can apply to the HPCSA to clear whether their practice in a spa, salon or corporate structure is ethically sound, by written application, inspection of premises, proof of training and scrutinising any contracts or agreements. This should occur before any agreements are made.

Take home message

In light of the above, AAMSSA believes that the best practice model is one where beauty therapists, somatologists and dermal aestheticians work within their designated scope of practice, under the supervision of a doctor and in a medical practice – not the other way around.

The combination of beauty therapy and medical aesthetics is not, after all, a match made in heaven. Mixing aesthetic medicine with salons and spas is not an easy marriage, and should not be entered into lightly, no matter how romantic it might seem.


  • HPCSA Guidelines for good practice. Ethical booklets 1-16
  • HPCSA Policy Document on Business Practices
  • Texas Senate Bill TX SB2366 | 2019-2020 | 86th Legislature
  • Aesthetic Medicine Volume 5 No 2 April/June 2019 www.aestheticmedicinejournal.org
  • The Netherlands College of Medical Specialisms (CGS) Cosmetic Medicine Decree 10th April 2019

Written and reviewed by

Dr Debbie Norval MBBCH(Wits) D.Pall Med (UK) MPhil.Pall Med (UCT) Adv Dip. Aesthetic Med (FPD) President of AAMSSA

Dr Cobus Van Niekerk (AAMSSA Medico-Legal and Ethics committee)

To report any unsafe practice or if you have any queries please feel free to contact Karen Nel at AAMSSA info@aestheticdoctors.co.za

Find a doctor practicing aesthetic medicine by visiting www.aestheticdoctors.co.za

A2 Disclaimer: This article is published for information purposes only, nor should it be regarded as a replacement for sound medical advice. 

Issue 32 – December 2019 (Summer)

This article was written by Dr Debbie Norval and edited by the A2 team EXCLUSIVELY for the A2 Aesthetic & Anti-Ageing Magazine Dec 2019 Edition (Issue 32). 

A2 Magazine prints only four magazines each year – reporting seasonally on everything you need and want to know about aesthetics, anti-ageing, integrative medicine, quality and medical skin care, cosmetic dentistry and cosmetic surgery in South Africa – where to go, who to see, what to expect, something new and so much more! Never miss an edition – click here for more info about where you can buy the print and/or digital copy of A2 Magazine (including back copies).

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