So-called anti-wrinkle injections such as botox were once thought to be something women sought out to defy the aging process, but increasingly that is no longer the case.

The increased consumer demand, and guidelines that allow registered and enrolled nurses to use telehealth doctors to get scripts for the prescription-only drugs, have fuelled massive growth in the cosmetic injectables industry.

Peter Duncan, 63, has been getting anti-wrinkle injections for about five years, describing it as body maintenance to address a lifetime of sun exposure.

“I see it more as an extension of just a healthier lifestyle,” said Mr Duncan who recently returned from living overseas.

Jenny Kimmins, who has a background in general practice and skin cancer medicine, and has been working exclusively in the cosmetic industry for about a decade, has seen an increase in patients seeking anti-wrinkle treatments.

“Certainly the number of men that we treat has been slowly increasing over time, so it’s probably gone from 5 per cent in the early days of the clinic, and I think it would be probably somewhere between 15 and 20 per cent now,” she said.

Dr Kimmins has found the most common thing her male patients tell her is “their wife made them come in”.

“But I think what we see is that men are taking more care of their appearance,” she said.

“They are probably in the workplace for longer, maybe than they were before, and they do become conscious that maybe they feel like the old person in the office.”

How much is the cosmetic injectables industry worth?

Market researcher Grand View Research valued the Australian facial injectables industry at $4.1 billion in 2023, and forecasts it to grow 19.3 per cent every year until 2030.

The majority of the procedures were done for aesthetic rather than therapeutic reasons.

Bunnings-owner Wesfarmers has become a huge player in the cosmetic injectables industry.

The ASX-listed company owns SILK Laser Clinics, Clear Skin Care and Australian Skin Clinics.

Other major players include private equity giant KKR’s Laser Clinics Australia, and there are scores of other chains and private operators with sites on high streets and suburban shopping centres.

Market analyst Jun Bei Liu, from Tribeca Investment Partners, said the cosmetic injectables industry was still strong despite a drop-off in consumer spending as inflation and interest rates bit.

“We have seen quite a lot of corporate interest into this market as well.”

What’s driving the botox and injectables boom?

In Australia only doctors and nurse practitioners can prescribe the Schedule 4 drugs used for anti-wrinkle injections, or dermal fillers.

However, registered and enrolled nurses can use telehealth doctor services known in the industry as “scripters”.

The scripting business model works like this: Nurses pay a membership fee to access telehealth doctors who can prescribe a patient the anti-wrinkle drugs via video conferencing after conducting a short consultation and gaining the patient’s consent.

In New South Wales, doctors can prescribe enough product for a six-month treatment schedule, while it is up to 12 months in other jurisdictions.

There is a lot of money to be made — last year Wesfarmers paid $135 million to buy digital health company InstantScripts.

The online scripting business also includes InstantCosmetics, which offers a prescription service and injectable products to cosmetic clinics across Australia.

Other major players in the Australian cosmetic scripting market include Fresh Clinics and Juv’ae.

Scripters also typically buy the drugs in bulk and on-sell them to nurses.

The big brands provide training to their nurse members and referral networks for local doctors in case something goes wrong with a procedure.

Cosmetic nurse Priscille Vrljic was able to start her own business after signing up to scripting service Fresh Clinics.

“I have been a nurse for 10 years, and I’ve been in aesthetics for 8.5 years, and I’ve been on my own for 2.5 years,” Ms Vrljic said.

She said while the cost of living crisis had prompted some of her customers to space out their appointments, she was still seeing up to seven new patients a week.

Business booms but complaints rise

Cosmetic injectables are not without risk — the unwanted side effects of anti-wrinkle injections include redness, swelling, bruising, and drooping of the muscle that can last until the botulinum toxin type A (branded under names like botox and dysport) wears off.

Dermal fillers, which are commonly based on hyaluronic acid, and injected in cheeks, lips, and other areas of the face, are riskier.

Botched procedures can cause problems from blocked blood vessels to tissue death, stroke and blindness.

The Australian Health Practitioner Regulation Agency’s (AHPRA) cosmetic surgery hotline has received 1,282 calls from patients and doctors and 472 formal complaints or notifications about cosmetic procedures since it was established in September 2022.

Fourteen practitioners have been banned or restricted from practising while AHPRA investigates complaints lodged through its hotline, while a further 20 practitioners have had restrictions imposed on their registration as a result of completed investigations.

AHPRA is expected to tighten rules for the industry in the next few months, after updating guidelines in September last year confirming registered and enrolled nurses can use telehealth scripting services to prescribe the drugs used in non-surgical cosmetic procedures to patients.

AHPRA and the Therapeutic Goods Association (TGA) have also moved to clamp down on the industry by banning practitioners from advertising branded products and using “before and after” photos, which were rife on social media.

Sydney Law School academic Christopher Rudge said further guidance from AHPRA might include more detail on the use of scripting businesses.

“The question is probably where a course of treatment begins and ends,” Mr Rudge told The Business.

“If a nurse practitioner [or doctor] prescribes 10 prescriptions of a cosmetic injectable, does that mean that the nurse practitioner [or doctor] has to see the patient each time that they are prescribed the medicine? 

“Or can they prescribe 10 and then they can visit a nurse, an enrolled nurse, following that point, and be administered the injection by that enrolled nurse — that is a question that’s yet to be explored, although I think there’s some room to look at the reforms closely in that regard.”

He noted that any further crackdowns, while aimed at protecting consumers, could curb the industry’s growth.

“These are … what might be called soft law reforms, but they will be able to be used in disciplinary proceedings against health practitioners if they are contravened,” Mr Rudge said.

“This so-called reform effort or crackdown on the cosmetic injectable sector … emerges from a broader review of cosmetic surgeries in Australia.

“It’s interesting that cosmetic surgeons are now asked to upskill by doing an extra education program to be identified as endorsed cosmetic surgeons.

“I don’t think that’s likely to happen in the future, but it’s something that could be considered if we see more harm arising out of this industry.”

Rise of ‘scripters’ raises alarm bells for some

Some in the cosmetic injectables industry are concerned about the rise of scripting businesses, particularly when the prescribing doctor is not locally based.

Scripting businesses defend the practice and argue they can link patients to other doctors closer to where they live if things go wrong.

“I would just encourage people to know the qualifications and the experience of the practitioner that they see,” Dr Kimmins told The Business.

While Dr Kimmins has no issue with nurses performing cosmetic injectables, she believes regulators should consider mandated training standards, responsibility to patients and a review treatment environments. 

“We are seeing a bit of a trend where there are some who are entering nursing purely to do cosmetic nursing.

“My personal opinion is they should actually have a minimum level of hospital experience, whether it’s 12 months or two years, so they know how to handle emergencies and they know how to deal with problems that might arise in patient care.”

Fresh Clinics declined to be interviewed for this story, but Ms Vrljic said the scripting service could provide access to a doctor within minutes if she had any questions or if a medical problem arose.

“You will just contact the doctor that scripted you and your patient, and they will contact you immediately … so there is actually always someone available, which is amazing,” Ms Vrljic said.

“I’ve never had to wait for more than, like, 3 minutes for a doctor.

“Accountability and patient safety and compliance is really, really big. We do compliance checks monthly and checking we are all above board and doing the right things.”

While many Australians have become accustomed to softening their wrinkles with regular injections of botulinum toxin or using dermal fillers to sculpt their face, Tribeca’s Jun Bei Liu is not so optimistic about the industry’s growth.

“We know many industry players, particularly some of the private-equity-owned players, are now struggling somewhat because competition is high and the prices [of treatment] have fallen, because consumers are unwilling to spend,” Ms Liu said.

She expects to see more mergers and consolidation as competition threatens the bottom line of more established brands and regulators clamp down on the industry.

“The growth forecast will be very tough,” she said.

“I do think they (growth predictions) will decline … The industry is facing a lot of challenges in the next 12 months.”