Social media driven validation and increased focus on good looks have created a huge demand for dermatologists. Doctors promise the moon to the people who are willing to go to great lengths for good skin – for a fee. Driven by commercial interests where doctors compromise ethics and duty towards humanity, Dr. Sushil Tahiliani, consultant dermatologist with the Mumbai-based PD Hinduja Hospital & Medical  Research Centre, tells Geetanjali Minhas that billions of rupees are being made selling a dream; driven by economics, doctors are veering towards making people younger and fairer.  
      
Excerpts of interview   

Please tell us about the latest developments in cosmetology in India. What is driving this segment?
Patients desire to look good, have fair complexion, lustrous hair on scalp and look young. We are veering away from the disease dermatology, which I practised when I started, and moving towards desired dermatology. Earlier people would come to doctors with the disease for treatment. Now they are fine with it, but want the doctor do some magic so that they can look younger, brighter and can have more hair on the scalp.

[This is] thanks to the influence of social media and glamorous pictures – and we all know that social media companies employ influencers. People feel they are gaining knowledge and being educated when they are being targeted to get influenced.

Yet, people thank doctors for good treatment and next want to know daily post-care schedule. We tell them about the importance of cleansing, moisturising, toning and using sun screen. They feel that is not enough and want to know if they can add a retinol, niacinamide or vitamin C and if they can get an AM and PM schedule. In short, people are out to coat their skin 24x7 and not let it breathe at all.

And all that will only affect top 2mm of skin. If they believe they are going to look young forever, aging does not involve only the top 2 mm of skin. It goes deeper inside for which nothing is sold. But this top 2 mm is marketed so well that billions of rupees are being made selling a dream. People are being sold a dream.

As a doctor, what is your message to such people?
They should understand that we are born infants. We grow to become teenagers, then adults… middle-aged and then old. Nobody can change that. You can only slow down the clock. And if you want to turn it back, at the most you can age more gracefully and stay healthy. Automatically skin will be brighter.  But we should not try to turn the clock back by 30-40 years. That creates freaks. We should all agree that we may postpone the inevitable for [a maximum of] 5 or 10 years.

Many of these treatments have a shelf life and one has to keep repeating them. Sometimes things go wrong. Even if things do not go wrong, treatments will not last for a long time. In India, everybody wants to become fairer and they do not want to get tanned. So, I tell them the best thing is not to step out of the house or else to use sunscreen every three hours. Even though tanning protects us from getting skin cancers, people are very unhappy getting tanned. We should feel blessed that we are able to tan.

What are the common skin problems with young people in India?
There are 3,300-odd skin conditions. As a senior dermatologist, I see many of those. But acne, psoriasis, fungal infections, pigmentation disorders/ darkening of skin and eczema together make more than 80% of our practice.

What advanced techniques are being used in dermatology?
We have devices like dermatoscopes, woods lamp and some bedside investigations that help us diagnose more accurately. We document better through digital photographs, use advanced techniques and treatment and not just look at the patients with the magnifying lens.

Earlier we used only conventional systemic drugs for severe psoriasis, followed by small molecules. Now we have biologics [a group of drugs]. In India itself, we have six biologics. Abroad there are 13 biologics. Things are evolving at a very rapid pace. I would say these are challenging but exciting times. If you love your subject and keep updated, you can manage your patients better than we could in the past.

India is considered the pharma capital of the world in terms of dermatology. How refined is the segment?
India is known to be good at producing generics at a very fairly good quality and a reasonable price. We have access to many drugs except for the ones which are under patent. The moment, the patent is over we are ready to prepare generic version.
 
For local skin products applied on the skin, what matters is the vehicle (inactive creams, lotions, solutions and/or ointments that change the properties of the medicine mixed into them for assisting its application) in which it is produced. The cream, ointment or lotion should have a very good, refined vehicle. Unfortunately, in India, in the generic format, we do not work very well on the vehicle.

What is the importance of skin banks in dermatology?
Skin graft helps only when there is total loss of skin. For the skin not to get rejected, the donor must be on immunosuppressive drugs. …you can use amniotic membrane from contents of a placenta after the baby is born and you have skin substitutes which are applied in cases where skin is lost, for example, non-healing ulcers or burns, but they do not put human skin there. There are always bioequivalent products which are available, which can be used for management. It not like patient with psoriasis has skin failure; we remove the skin and put somebody else's skin. In dermatology we do not work on skin like that. You can repair it.

Since Covid-19, people are more inclined towards natural remedies like Ayurveda. Please give us your views on it.
Whatever you follow should be evidence-based. It has become a fashion….a fad… In Allopathy everything is mentioned threadbare in social domain and drugs are being constantly improved for future.

In 1947, at the time of independence, when our population was less than 50 crore and Allopathy was at nascent stage, people used natural therapies only. But average longevity of a male was mid-50s and for women, it was 52 years. If somebody lived to be 60, there would be havan and yagna. In those days there used to be 49 new births per 1,000 population, per year. Whereas now, there are less than 10 births per 1,000 population per year and still the population is going up, there are less than 2 deaths per 1,000 population per year. In those days the rate of birth and death matched. There used to be 48 deaths per thousand population per year. It is so common to have people who live to be mid-80s and early 90s which was a rarity earlier. This is what Allopathy has done. You should to take a balanced view and look at what good has happened to people. Now, good products and facilities are available.

Naturopathy too has good products. But everything has a limitation. They make claims and based on those claims they sell. Whatever you propose to promote and propagate should be evidence-based. I'm sure that there is no debate on that. There should be proper studies in institutes.  

Is enough research taking place in India on skin diseases?
Not the way it should be done. As a doctor, if I have spent 40 years reading my patients, I would not mind being a research scientist. But who sets up research centres? You have people who invest in five-star hospitals because they know return on investment will be good. There should be a concept of people putting in some money in research where they do not look at profits. We have enough people with money who want to, but we don't have the concept of doing it. That should be inculcated in people's minds.

How are Artificial Intelligence and digital tools helping address issues in dermatology?
For sure, there are benefits, during Covid-19 and even otherwise. Daily I consult at least four patients from all parts of the world, online. I talk to them face to face and I give them advice. They know there are good doctors available in India at reasonable rates compared to what they have to pay in their own countries. People from remote places in the country also call for consultation. This is the benefit of technology.

We have tools in AI where more than 30 diseases can be diagnosed to more than 90% accuracy. If I am a trained doctor who can study a rare condition and have AI tools for all the diseases, I'll be very happy because, it will give me a fast clue for rare syndromes otherwise I will have to read the journals. For example, a primary health care provider in a PHC where a dermatologist is not available can check the patient for disease and be able to use the app for rough diagnosis, based on that, a decision can be made if the condition is serious or not .

Are there any interventions required for further development of dermatology in the country?
A balance is required. We are veering only towards making people look younger and fairer. There is very limited level of evidence there, but there is so much glamour and that is driving the commercial interest. There are people who have given up on Clinical Dermatology and refer patients to me because they feel consulting patients on psoriasis etc, does not give them enough income. But if they can give one Botox injection, in 10 minutes they can earn a good amount. So economics is driving people … there are no emergencies in such cases, you can work till 7 pm, go to the health club, do clubbing, have parties and still make good money.

How can diagnostic, therapeutic and cosmetic dermatology be made more affordable for larger sections of the society?
Cosmetics should not be. If people see a dermatologist and if he can just treat them and let them have healthy skin, that is affordable. And if that is not affordable, there are many charitable centres, public hospitals where doctors are available practically free. But when they prescribe a medicine, how many pharma companies are willing to provide them at charitable rates?

I do my job, if I advise an investigation, …Lions Club will do an investigation at a cheaper rate. What about the medicines? How many pharma companies are willing to work free… or keep part of their income for such cases? Doctors do charity and are pressured to do more charity. What about others? Other than the doctor, everyone is a businessman.

If the patient decides to do cosmetic dermatology to look younger, wants to take unethical injections to become fairer, how can that be charitable and affordable? That is the patients’ foolhardiness and they asked for it. So for that, they have to pay. But then people have been made to feel they are born inadequate and start suffering from Body Dysmorphic Disorders. It is a make-believe world.