Work in progress. Please excuse the mix of present and past tense! The most commonly understood descriptions are used for the moment, as there were many manufacturers and brand names involved.
| Treatment or product | Amphetamine-like appetite suppressants | Retinoic Acid (Tretinoin) | Laser/IPL | Botox(tm) |
| Concept is established for off label use or for tenuous reasons by stakeholders in the medical community. | Guidance for prescribing appetite suppressants on the NHS gradually phased out due to lack of evidence of success and ethical concerns. | Acne medication retinoic acid has the side effect of smoother skin reported by users. | Laser devices used by dermatologists for vascular lesions were observed to cause slow regrowth of hair. Medical device manufacturers refine their equipment and methodology to target hair specifically. | Patients receiving Oculinum injections for eye issues related to muscle report smoother skin and a reduction in deep lines. |
| Business interests expand access to the public via private medical provision. | Private doctors continue prescribing. Regulated under Misuse of Drugs Act 1971. | Dermatologists start to prescribe Retin A (the brand name) off label as a treatment for photo ageing. | Laser hair removal devices are marketed to dermatologists and plastic surgeons. | Plastic surgeons and dermatologists begin to use it for cosmetic reasons. |
| First signs of conflict from medical professionals, adjacent occupations that have co-opted, and public concern | E.g. 11th May 1989 debate on slimming clinics in House of Commons. | Johnson & Johnson ™ start a 5 year trial in 1985 in order to achieve FDA approval for this use. | The Registered Homes Act 1984 only regulated class 4 lasers were covered and only the premises were inspected. In 1996 the Department of Health were asked to review this by doctors, laser safety experts and local authorities. Mount Vernon Hospital begins a study into claims made. Laser manufacturers target beauty therapy organisations (in particular electrolysists) but preliminary tests result in burns and a stipulation that only doctors should perform the treatments. | 1989 manufacturer Allergen rebrands drug as Botox and receives FDA approval for therapeutic use. Starts clinical trials for safety and efficacy. |
| Marketing blitz floods the media and availability is rolled out quickly and extensively. | Diet clinics become the main supply point for appetite suppressants. Herbal remedies with stimulant effects become available on the market via non-medical occupations. ‘Safer’ drugs such as Fen-Phen receive positive coverage. | While the 5 year trial is taking place, a J&J subsidiary called Ortho Pharmaceutical runs a large media campaign focusing on the reduction of wrinkles, making the public aware that it was available on private prescription. | Laser clinics are set up. Beauty therapists with medical training (especially ex nurses who are still registered) are sold equipment packages on lease purchase, making it affordable to offer. Enormous amount of media coverage. IPL is marketed as a safer alternative without needing medical supervision. | Early 2000s After FDA approval a cosmetic version of Botox is marketed specifically as an aesthetic treatment (with no medical claims). Health related professions and occupations with authority to administer injected medication are able to offer the treatment in the UK as it is still prescribed as a medication. At one point over a third of all Royal College of Nursing registrants were offering Botox along with other similar treatments (most notably fillers) in a non-medical setting. |
| Discontent over injuries and adverse effects bring increased attention of policy makers | E.g. Royal College of Physicians Working Party of Obesity Management release a report in 1997 stating that drugs should be used as a last resort. (Report no longer available). E.g. of media attention 2nd June 1996 Sunday Telegraph “Diets and a Quack Profit” by Ross Clark. | Irritated and broken skin caused by Retin A start becoming a common place issue reported by users. Questions raised by dermatologists over whether it required the use of sun protection. Beauty therapists report problems such as skin being removed during waxing, and increased | Permanent removal is not achieved and medical, leading to insurance claims. Burns and adverse effects attract attention of the media (BBC Watchdog run a hard hitting piece on primetime TV). | 2003 The National Care Standards Commission highlight the inability to properly monitor and report on cosmetic surgery establishments in general. Misleading claims are routinely made regarding non-surgical procedures. Plastic surgery membership organisations highlight poor practice in botox and fillers in particular. |
| Long cycle of initiatives and regulatory attempts | 1999 RCP strengthens guidelines. Doctors face being reported to GMC if they do not follow them. 2000 Phentermine and Diethylpropion are technically banned (withdrawn from use and licence taken away) but private clinics and drug manufacturers successfully argue the side effects don’t justify banning, and customers should have the choice. Diet clinics and private doctors are included in the Health and Social Care Act 2008, meaning they must be registered with the CQC. | 1988 The FDA issues a warning over the marketing claims made and poor practice by dermatologists. Ortho were eventually fined in 1995. A lower dose product receives FDA approval for marketing. Further research into vitamin A derivatives leads to retinol as a less aggressive alternative. There are attempts to restrict these to medical professionals only as it is mainly prescribed for oral use in vitamin A deficiency. | The Care Standards Act 2000 required laser and IPL clinics to register with the appropriate authority in the devolved nations. In 2003 this was updated to make the Care Quality Commission the appropriate authority throughout the UK. In 2010 laser and IPL for non-medical use was removed from the CQC remit and entered the private domain (only 2 people were prosecuted and it was estimated that nearly 3/4 of non-medical clinics were unregistered). The decision was made under the EU directive for Better Regulation and assessed on the number of adverse effects. Local Authorities (most noticeably the London boroughs) brought in a Special Treatment licence to include lasers and IPL. | The Cayton Review and a report by the Healthcare Commission both highlight the need to monitor the growing availability of botox (and increasingly fillers). The delegation of treatments is not possible to monitor. No legislative changes are made due to the lack of evidence of significant risk. The Keogh Review of the Regulation of Cosmetic Interventions repeats the same ground. |
| Narratives become incompatible. | Appetite suppressants remain on the market via the private sector. They are viewed as a legitimate weight loss route by customers, comparable to popular diets and exercise. The main medical bodies publicly voice opposition to appetite suppressants but their members continue to engage in prescribing them privately. The media reports on the dangers of diet drugs but continue to promote unhealthy body images. | The skin damaging aspects of retinoic acid and retinol become well established. They continue to be prescribed for photoaging by medical professionals despite no legislation allowing this in the UK. | Qualifications are created for non-medical use of IPL devices and incorporated into beauty therapy as an advanced treatment as per the Better Regulation guidance. Private device manufacturers create their own private training courses. Medical laser and IPL users continue to campaign against non-medical professionals using laser and IPL without medical supervision but continue promoting questionable claims. Use of laser and IPL devices expands to skin rejuvenation. | Medical professionals (doctors, nurses, dentists in particular) describe the treatment as a medical procedure, but do not acknowledge that it is their colleagues enabling non-medical professionals to carry out delegated treatments. Beauty therapy qualification and standards bodies turn down requests (some from Government bodies) to create training courses as it violates regulation for cosmetics and cannot be classed as a beauty treatment. Beauty trade magazines and shows continue to promote delegated treatment opportunities. Animal rights campaigners highlight the use of animal testing for cosmetic purposes. Manufacturers cannot avoid animal testing as it is a drug, but market it for cosmetic purposes. |
| Stakeholders create their own ad-hoc rules and norms. Issue remains unresolved. | The NHS promotes diet and lifestyle changes. The GMC do not stop members from prescribing and will only step in if there is a complaint made. The media starts to include more body positivity coverage. | Cosmeceuticals becomes a marketing term for skincare with ingredients that have a non-beauty affect on the skin. Prescription guidelines for acne tend to be followed when prescribed off label by medical professionals. Retinol in beauty products is marketed mainly at over 40s. | Beauty therapy devices are restricted (by responsible manufacturers) to reduce side effects and offer long term results for hair and skin treatments. National Occupational Standards restrict the use to healthy skin only. Dermatology treatments on the NHS are severely reduced partly due to lack of success for acne treatments, leading to more private provision and a more established private sector using medical lasers for non-medical use. | Ongoing. |