You’ve probably seen the statistics on the recent growth of medical spas in the U.S. Among them: From 2010 to 2023, the number of medical spas nationwide grew nearly sixfold, from about 1,600 locations to more than 10,000, reflecting a huge appetite among Americans for injectables, laser treatments, chemical peels and other nonsurgical cosmetic procedures.
The trouble with this trend is that it is being driven overwhelmingly by medical spas owned and operated by nonphysician providers, particularly nurse practitioners (NPs), most of whom are practicing with no physician supervision. In fact, according to an AMA issue brief on the need to protect patients with physician-led care at medical spas (PDF), 70% of medical spas lack any affiliation with a physician practice.
But the problem runs much deeper. It turns out this rapid growth is largely due to the fact that, in many states, there is literally no regulatory oversight of medical spas. None at all.
A study published in the journal Dermatologic Surgery summarizes the legislative landscape governing ownership, operation and scope of practice for nonphysician providers at medical spas in each U.S. state. Learn where your state stands.
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Using data from legal and medical databases—including Westlaw, Lexis Nexis, PubMed and Google Scholar, as well as from the American Society of Dermatologic Surgery Association (ASDSA) and state government documents—from 2000 to 2024, the authors looked at state regulations around licensure, medical directors, ownership and operation, patient protection, and scope of practice and supervision.
The study’s supplemental material details the findings in each area. Nearly there-quartes of states—36—have zero regulations or laws in place for medical spas, and 44 states lack patient-protection regulations specific to medical spas.Those with any regulations at all were Connecticut, Iowa, Illinois, Indiana, Massachusetts, New Mexico, Oklahoma, Rhode Island, Tennessee, Texas, Utah and Wisconsin.
The numbers were even worse for licensure. All states but two had no identifiable requirements. In Massachusetts, medical spas had to be licensed as a clinic unless “wholly owned and controlled by one or more of the practitioners.” Only Tennessee required medical spas to register with the state.
No regulations means no recourse
The ramifications of the lack of regulation can be profound and lasting for patients, said Rachel Kyllo, MD, a board-certified dermatologist and fellowship-trained Mohs surgeon specializing in surgical and cosmetic dermatology at Meramec Dermatology, in St. Louis, Missouri.
“If someone is burned by a laser that I performed, or if somebody has a scar from a procedure I performed, and they're unhappy with that outcome, they have the ability to go through the medical-legal system and seek recompense,” said Dr. Kyllo, who is also a delegate to the AMA House of Delegates from the American Society for Dermatologic Surgery Association.
“I have to carry malpractice insurance with appropriate limits for that kind of thing,” she said. “But these med spas don’t. So when somebody is burned by a chemical peel that was too strong for their skin type, or they are left with permanent scarring from a laser that was used inappropriately, and they try to get money just for the medical bills that result, they find that no malpractice attorney will take their case—because there's no purse.”
As part of its long-running efforts to fight scope expansions, the AMA defends the practice of medicine against scope of practice expansions that threaten patient safety and undermine physician-led, team-based care.
Uniformity, consistency needed
Dr. Kyllo did not take part in writing the Dermatologic Surgery study. ASDSA Immediate Past President M. Laurin Council, MD, is one of the study’s co-authors and was previously interviewed for an earlier AMA news article about the lack of physicians on site at most med spas.
Dr. Council and her co-authors made several recommendations to lawmakers.
“Regulatory reform for medical spas in the U.S. should focus on establishing consistent standards across states to improve patient safety and care quality,” they wrote. “To address these inconsistencies, overarching guidelines could provide states with a baseline regulatory structure, ensuring uniform standards for licensing, training and operation. This would enable states to adopt regulations that are both comprehensive and adaptable, allowing for state-specific needs while ensuring baseline safety and practice standards.”
Physician oversight is also essential in medical spa operations, particularly those involving high-risk procedures, such as laser treatments, dermal fillers and injectable neurotoxin.
“By requiring physician supervision and enforcing specific training standards for NPPs, states can better safeguard patients against complications associated with improperly administered treatments,” the authors wrote.
They added that regulators should also focus on enhancing patient protections, “particularly in the areas of informed consent and advertising, to help protect patients from misleading or harmful practices. In addition, states could consider implementing mandatory reporting requirements for adverse events associated with medical spa treatments, similar to those in place for other medical facilities.”
These suggestions align with the ASDSA’s Medical Spa Safety Act model legislation, which calls on states to regulate medical spas and can be found on the association’s webpage dedicated to the issue. This comprehensive resource also features information on recent research, state regulations, government guidance and adverse events.
Learn more with the AMA about what sets apart physicians and nonphysicians.
The missing link: patient testimony
“It often takes a very high-profile event in which someone dies for something to be done legislatively, which is sad,” Dr. Kyllo said.
The key, then, is getting patients who have been harmed to speak up.
“It's a hard ask,” she said. “What we hear as people managing these complications is, ‘Well, I knew it probably wasn't a good idea to get this done in somebody's garage.’ There's a bit of self-guilt there. So testifying at the state legislature or speaking to a reporter and having photographs of your burns displayed is painful. But ultimately that's what's really going to move the needle, because we can present all the facts we want to state legislators, but it's much harder for them to look somebody in the eye who’s had a bad complication and say, ‘We don't care about that.’”
If you are a physician who has seen a patient who was harmed at a medical spa, Dr. Kyllo recommends referring the patient to a board-certified dermatologist or a plastic surgeon for management of active problems and/or scarring.
In addition, the ASDSA has a website, the Cutaneous Procedures Adverse Events Reporting Registry, through which physicians can report these issues.
"The anecdotes—the personal stories—are often what have the most impact,” Dr. Kyllo said.
Through its Advocacy Resource Center, the AMA works directly with national, state and specialty medical societies to enact state laws and regulations that protect patients and support physicians—and fight back against those that do not.
