Title: Cosmetic and Dermatologic Procedures
Advisory Ruling Number: 1301
Authority: The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.G.L.) c. 13, §§ 13, 14, 14A, 15 and 15D, and G.L. c. 112, §§ 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education. In addition, M.G.L. c.30A, § 8 authorizes the Board to make advisory rulings with respect to the applicability to any person, property or state of facts of any statute or regulation enforced or administered by the Board. Each nurse is required to practice in accordance with accepted standards of practice and is responsible and accountable for his or her nursing judgments, actions, and competency. The Board’s regulation at 244 CMR 9.03(6) requires all nurses to comply with any other law and regulation related to licensure and practice.
Date Issued: November 13, 2013
Date Revised: June 14, 2017
Scope of Practice: Registered Nurses and Licensed Practical Nurses
Purpose: The purpose of this Advisory Ruling is to guide the practice of the Registered Nurse and Licensed Practical Nurse (nurse) who may perform cutaneous procedures that utilize non-ablative laser and non-laser light sources and/or who may perform aesthetic procedures that utilize chemical solutions, micro-particles, soft tissue augmentation, or injections of solutions/medications or soft tissue fillers as part of their nursing practice.
Advisory: The nurse licensed by the Massachusetts Board of Registration in Nursing (Board) is expected to engage in the practice of nursing in accordance with accepted standards of practice. The nurse must only assume those duties and responsibilities within the scope of practice for which necessary knowledge, skills, and abilities have been acquired and maintained. The nurse may perform cosmetic and dermatologic procedures as part of an overall comprehensive plan of care to treat various dermatological conditions or as part of a health maintenance/health promotion regime. The procedures are non-diagnostic in nature and do not involve the removal of tissue.
It is the Board’s current position that it is within the scope of practice for the licensed nurse to provide cutaneous procedures that utilize non-ablative laser and non-laser light sources and/or aesthetic procedures in settings that comply with M.G.L. c. 111, § 51 and subsequent declarations of agencies that provide setting oversight, including, but not limited to the Department of Public Health and the Board of Registration of Cosmetology. Provision of ablative procedures by laser are limited to Board authorized advanced practice nurses.
For the purpose of this Advisory Ruling, procedures include, but are not limited to:
- Non-ablative, non-vaporizing laser or light-based devices used for hair removal, photorejuvenation, acne, spider veins, vascular and pigmented lesions, and tattoo removal;
- Chemical peels;
- Administration of absorbable fillers;
- Administration of Botulinum exotoxins;
- Sclerotherapy; and
Cosmetic and dermatologic procedures that involve the practice of acupuncture are regulated by the Board of Registration in Medicine and are not within the scope of nursing practice. Examples of such procedures include, but are not limited to:
- Dry needling; and
- PDO (polydioxanone) thread embedding.
The nurse must acquire education that includes a supervised practicum resulting in a competency evaluation commensurate with the procedure. Components of the education include, as appropriate to the specific procedure, but are not limited to:
- Anatomy and physiology;
- Pathophysiology of the integumentary system and supporting structures;
- Cosmological and dermatologic conditions;
- Wound healing principles;
- Safe use of product/device/equipment ;
- Side effects and management;
- Management of emergencies; and
- Patient and environmental safety.
When the procedure includes the use of non-ablative, non-vaporizing laser or light-based devices, the nurse must have evidence of successful completion of a Laser Physics and Safety course that includes relative content from the Occupational Safety and Health Administration (OSHA) and American National Standards for the Safe Use and Handling of Lasers in Health Care Facilities (ANSI) that includes both a didactic portion and a practicum.
Nurses licensed by the Board practice within their scope, are responsible and accountable for their nursing judgments, actions, and competency and do not perform activities outside their scope of practice.
Although the patient assessment must be performed and documented by a registered nurse or duly authorized prescriber, the performance of the procedure is pursuant to the orders of a duly authorized prescriber. The nurse must verify the orders from a duly authorized prescriber include the patient’s name, valid order date, medication or substance name, dosage, route, anatomical site for administration, specific administration directions and prescriber signature.
A nurse licensed by the Board can only perform acts with the scope of nursing practice as defined at M.G.L c 112 § 80B and 244 CMR 3.00 and 9.00. It is not within the scope of practice for a nurse who is not authorized to practice as an advanced practice registered nurse (APRN) to medically diagnose, or to prescribe medications or treatments. Therefore, for the purpose of this advisory, it is not within the scope of the LPN or RN who is not authorized as an APRN with prescriptive authority to:
- select the medication/solution, dosage, device or device setting to be used in the performance of a cosmetic or dermatological procedure; or to
- purchase or obtain a drug, substance, controlled substance analogue or immediate precursor in any schedule or class referred to in MGL c. 94C to be used in the performance of a cosmetic or dermatological procedure independently or as an agent of the prescriber.
Further, to perform cosmetic and dermatologic procedures that involve acupuncture a nurse must have a current MA acupuncture license.
It is the Board’s position that nurses whose practice includes cosmetic and dermatologic procedures may not practice in an organization that does not have policies and procedures that include:
- A requirement for informed consent;
- A requirement for a comprehensive, documented evaluation;
- Recommendations for self care;
- Follow-up recommendations;
- Situations that require referral;
- Management of side effects; and
- Provisions for emergent care.
Documentation criteria must include:
- Review and verification of informed consent that clearly informs the patient of the operator’s qualifications, licensure, and expected outcomes of the procedure;
- Assessment data inclusive of past medical, surgical, allergy and medication histories;
- Skin typing/classification;
- Sun exposure history;
- Current cosmetic/dermatologic product usage;
- Exclusion from treatment criteria;
- Identification of and evaluation of test site as indicated;
- Specifics of procedure performed and patient response to procedure; and
- Directions for referral back to or consultation with the duly authorized prescriber of procedure.
The nurse must document and provide the patient with written pre and post procedure education which includes, but is not limited to, self-care instructions and follow-up recommendations inclusive of continued and emergent care needs.
Advance Practice Registered Nurse
In addition to the procedures above, it is in the scope of practice for a Board authorized advanced practice registered nurse with appropriate competence acquisition, to perform ablative or vaporizing laser cosmetic and dermatologic procedures.
- Dermatology Nurse Association The Nurse’s Role in the Use of Laser, Light, and Energy Emitting Devices at www.dnanurse.org/advocacy/position-statements/laser-light-and-energy-emitting-devices.html and The Nurse’s role in the Provision of Cosmetic Services at www.dnanurse.org/advocacy/position-statements/nurses-role-provision-cosmetic-services.html undated, accessed 9/27/16
- Massachusetts Report of the Medical Spa Task Force Established by Chapter 81 of the Acts of 2006, published January 12, 2009
- American Society for Dermatologic Surgery Association Laser Hair Removal and Cosmetic Dermatology at www.asds.net/LaserHairRemovalInformation.aspx undated, accessed 9/27/16
- Food and Drug Administration Cosmetic Devices at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/CosmeticDevices/default.htm6/04/2014, accessed 9/27/2016
- Occupational Safety and Health Administration Use of Medical Lasers at www.osha.gov/SLTC/etools/hospital/surgical/lasers.html accessed 9/27/16
- American National Standards for the Safe Use and Handling of Lasers in Health Care Facilities, December 5, 2011at https://de356l4tocdyu.cloudfront.net/pdf/Z136_3_s.pdf Laser Institute of America, American National Standards Institute, Inc. accessed 9/27/16
- Massachusetts Department of Public Health Advisory on Medical Spa Services, undated, accessed 9/27/16 at www.mass.gov/eohhs/gov/departments/dph/programs/hcq/healthcare-quality/health-care-facilities/clinics/medical-spa-services-advisory.html
- Massachusetts Board of Registration of Cosmetology Policy Bulletin Regarding Prohibited Practices undated, assessed 9/27/16 at www.mass.gov/ocabr/licensee/dpl-boards/hd/regulations/board-policies/policy-bulletin-prohibited-practices.html
- Massachusetts Office of Consumer Affairs and Business Regulation (Consumer Advisory: Botox® 11/4/2010 accessed 9/27/16 at www.mass.gov/eohhs/docs/borim/physicians/publications/advisory-botox.doc)