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In this episode of Skin Anarchy, Dr. Ekta Yadav sits down with Tom Terranova to unpack a topic that is rarely discussed openly in aesthetics: safety infrastructure. While patients often focus on outcomes, pricing, or provider reputation, there is an entire layer of operational, clinical, and regulatory oversight happening behind the scenes—or in many cases, not happening at all.

Terranova introduces the mission of QUAD A, a nonprofit founded to establish third-party, evidence-based safety standards as procedures transitioned from hospitals into outpatient settings. What began in surgical environments has now expanded into one of the fastest-growing and least standardized areas of healthcare: med spas.

The Med Spa Gap: Where Medicine Meets Consumerism

Aesthetic medicine exists in a uniquely blurred space between healthcare and consumer beauty. As Terranova explains, this shift has fundamentally changed patient behavior. Treatments are increasingly patient-driven, often approached with the same mindset as booking a facial or hair appointment—despite involving injections, biologics, and tissue disruption.

The challenge is that while expectations of safety remain high, regulatory oversight has not kept pace. In many regions, there is little to no uniformity in who is qualified to perform procedures, what training is required, or how facilities are monitored. This creates a fragmented system where two clinics offering the same treatment may operate under entirely different standards of care.

Risk Is Not Binary—It’s Stratified

One of the most important contributions of QUAD A’s new initiative is the introduction of risk stratification in non-surgical aesthetics. Unlike surgery, where anesthesia levels clearly define risk, med spa procedures have historically lacked a structured framework.

Terranova describes a tiered system ranging from low-risk treatments to procedures that should not be performed outside of surgical settings. This model reframes how providers—and patients—should think about aesthetic interventions: not as universally “low risk,” but as variable in complexity, invasiveness, and potential for harm.

Credentials Are Only the First Layer

While much of the public conversation focuses on who is holding the needle, Terranova emphasizes that credentials alone are insufficient. Training pathways vary widely across states and countries, and in some cases, regulations are minimal or poorly enforced.

More critically, technical skill does not guarantee preparedness. A provider may be highly proficient in performing injections, but without training in adverse event recognition and response, even minor complications can escalate. Safety, in this context, is not just about execution—it’s about clinical judgment, escalation protocols, and team-based response systems.

The Reality of Adverse Events

A key theme in the discussion is the under-recognition and under-reporting of adverse events in aesthetic medicine. While many procedures are statistically low risk, they are not risk-free. Complications such as vascular occlusion, tissue necrosis, and even blindness, though rare, are well-documented.

What is more concerning is that these events are often not properly identified or documented, particularly in non-clinical environments. Without standardized reporting systems, both patients and providers operate with an incomplete understanding of true risk.

This is where accreditation becomes critical—not as a guarantee of perfection, but as a framework ensuring that providers can recognize, respond to, and manage complications appropriately.

Safety Is Operational, Not Just Clinical

Beyond individual providers, QUAD A’s approach evaluates the entire operational ecosystem of a facility. This includes infection control protocols, equipment maintenance, medication storage, documentation practices, and emergency preparedness.

These are not elements patients typically see, but they are foundational to safe care delivery. A well-designed facility ensures that safety is systematized and repeatable, rather than dependent on individual discretion.

Terranova likens accreditation to a driver’s license—not a promise that mistakes will never happen, but a demonstration that the provider understands the rules and can operate within them consistently.

Rebuilding Trust Through Transparency

At its core, this conversation highlights a growing disconnect between perceived safety and actual safety in aesthetic medicine. Patients often assume that all healthcare environments operate under similar standards, when in reality, oversight can vary dramatically outside of hospitals.

QUAD A’s expansion into med spas represents an effort to close that gap—bringing structure, accountability, and transparency to an industry that has scaled rapidly without unified safeguards.

For patients, this shift is equally important. As aesthetic procedures become more accessible, informed decision-making must evolve alongside them. Understanding not just what treatment you’re receiving, but where and how it’s being delivered, is essential.

Listen to the full episode of Skin Anarchy to hear Tom Terranova break down the safety gaps in aesthetic medicine, the evolution of accreditation standards, and what every patient should understand before choosing where to get treated.

Introduction Skin cancer is the most common form of cancer in the United States. According to the American Academy of Dermatology, more than 9,500 people are diagnosed every single day. Each year, millions are treated for basal cell carcinoma, squamous cell carcinoma, or melanoma. For many Americans, particularly those with fair skin, skin cancer prevention is a routine part of healthcare messaging: wear sunscreen, avoid tanning beds, check your moles. But that messaging has not always been inclusive. While skin cancer accounts for nearly 40% of all cancers diagnosed in White patients, it accounts for approximately 1–2% of cancers in Black patients. At face value, that difference suggests risk is dramatically lower in darker skin tones. However, the more alarming statistic is not incidence. It is stage at diagnosis. Approximately 52% of Black patients diagnosed with melanoma present with advanced-stage disease, compared to about 16% of non-Hispanic White patients. Once melanoma progresses beyond early stages, survival rates decline significantly. When caught at stage I, five-year survival is approximately 99%. At distant stages, survival may drop to near 30%. This gap in outcomes is not explained by biology alone. It reflects disparities in awareness, education, access, and representation within dermatology itself. As conversations about equity in healthcare continue, dermatology is facing an uncomfortable truth: the specialty has not been structured around diverse skin tones. And the consequences are measurable. Incidence Is Lower But Mortality Is Higher Melanin provides some protection from ultraviolet radiation. This helps explain why UV-induced skin cancers are less common in people with darker skin. However, lower UV sensitivity does not eliminate cancer risk. Melanoma in Black patients often develops in areas not traditionally associated with sun exposure. The most common subtype is acral lentiginous melanoma. This form appears on thepalms, soles of the feet, or beneath the nails. These are areas that patients may not routinely inspect and clinicians may not consistently prioritize during limited-time appointments. Because these lesions are not immediately associated with sun damage, they are more likely to be misinterpreted or dismissed. A dark streak under a nail may be mistaken for trauma or a lesion on the sole may be assumed to be a callus or fungal infection. “For those who don’t treat melanin rich skin, they may mistake the fact that you can’t see redness as readily on melanin rich skin for not being as sensitive. But in many ways, melanin rich skin is exquisitely sensitive,” says Dr. Michelle Henry, MD. The issue is not that melanoma behaves more aggressively in Black patients but that it is more likely to go undetected until it has progressed. Late detection leads to worse outcomes, and this pattern reflects systemic failure in early recognition. The Longstanding Myth of Immunity For decades, public health messaging implicitly framed skin cancer as a condition affecting primarily White individuals. Campaign imagery, sunscreen advertisements, and educational materials often centered fair skin and visible sunburn. Research from the Centers for Disease Control and Prevention shows that sunscreen use is significantly lower among Black Americans compared to White Americans. Routine skin examinations are also less common. However, these behaviors do not occur in a vacuum. They are shaped by messaging and provider communication. If physicians are less likely to emphasize sun protection to patients with darker skin, those patients may reasonably conclude that prevention is unnecessary. Misconception operates on both sides of the clinical interaction. Patients may not raise concerns about suspicious lesions. Providers may not initially suspect malignancy. The combined effect is delayed diagnosis. Dermatology as a Visual Specialty and the Consequences of Limited Representation Dermatology relies heavily on visual pattern recognition. Students are trained to identify subtle changes in pigmentation, border irregularity, scaling, and texture. Historically, dermatologic education materials have overwhelmingly featured lighter skin tones. Many widely used textbooks and teaching slide decks included limited images of conditions on darker skin. Inflammation that appears red on lighter skin may appear dark brown, gray, or violaceous on melanin-rich skin. Eczema, psoriasis, lupus, and even melanoma can look markedly different depending on baseline pigmentation. If trainees are not consistently exposed to those variations, diagnostic accuracy can be compromised. In recent years, educators have acknowledged this gap. Some institutions have updated curricula to include more representative imagery. Online databases and clinical atlases now prioritize inclusion. However, many practicing dermatologists completed their training during periods when diversity in educational materials was minimal. The stage-at-diagnosis gap in melanoma reflects this history. Workforce Diversity: Why It Matters According to the Association of American Medical Colleges, Black physicians remain underrepresented in dermatology relative to their percentage in the U.S. population. Dermatology is one of the most competitive specialties, with limited residency positions and high academic requirements. The lack of diversity has implications beyond workforce statistics. Representation influences mentorship pipelines, research priorities, and patient trust. Black dermatologists are more likely to focus research on skin of color, pigmentary disorders, and disparities in outcomes. They also serve as mentors to medical students who may otherwise lack exposure to dermatology as a viable career path. Workforce diversity also impacts patient experience. Studies across multiple specialties demonstrate that patients often feel more comfortable and engaged when treated by providers who understand their cultural and lived experiences. In dermatology, where concerns may include cosmetic appearance, scarring, or hair practices tied to identity, trust is especially important. Improved trust can lead to earlier presentation and greater adherence to follow-up care. Structural Barriers to Entering Dermatology The pathway to dermatology is competitive and resource-intensive. Students are expected to complete research, secure strong specialty-specific letters of recommendation, and often participate in away rotations. These steps require mentorship and financial flexibility. Students from underrepresented backgrounds may face obstacles in accessing research opportunities or specialty mentors. Institutions without large dermatology departments may not offer the same exposure. Financial barriers also matter. Application and interview processes can be costly. Without structural support, disparities in specialty representation persist. Organizations such as the Skin of Color Society have developed mentorship programs aimed at addressing these gaps. Some residency programs have adopted holistic review processes to broaden applicant pools. However, progress remains gradual. Broader Impacts Beyond Melanoma Skin cancer is only one aspect of dermatologic disparities. Black patients experience higher rates of certain pigmentary disorders and keloid formation. Post-inflammatory hyperpigmentation can result from acne, eczema, or minor injuries. Improperly selected cosmetic treatments may exacerbate these issues. Laser procedures and chemical peels require careful adjustment for melanin-rich skin to avoid complications. Without adequate training across diverse skin types, patients may face avoidable adverse effects. As aesthetic dermatology expands, ensuring that practitioners are competent in treating all skin tones becomes increasingly important. Public Health Messaging and Industry Responsibility Public health campaigns have begun to shift toward inclusivity. Sunscreen brands increasingly market products to diverse consumers. Dermatology organizations emphasize that skin cancer can affect all skin tones. However, decades of messaging shaped public perception. Reversing that perception requires consistent and sustained effort. Media platforms and beauty publications also play a role in shaping awareness. When discussions of skincare include education about mole checks, nail streaks, and full-body exams for all skin tones, cultural norms shift. Improving awareness can lead to earlier detection. Demographic Trends and Future Implications The U.S. population is becoming increasingly diverse. Census projections indicate that racial and ethnic diversity will continue to increase over the coming decades. Dermatology must evolve to meet the needs of a changing population. If training programs and workforce demographics do not keep pace, disparities will likely widen. Improving representation is not solely about fairness. It is about preparedness. Signs of Progress Medical schools are incorporating more diverse images into curricula. Professional organizations are funding research on disparities in skin cancer outcomes. Residency programs are implementing diversity initiatives and mentorship pipelines. These changes are meaningful, but outcome data will determine whether they are sufficient. Reducing the percentage of advanced-stage melanoma diagnoses among Black patients should be a measurable goal. Closing that gap will require continued attention to education, workforce development, and public health communication. The Core Issue Skin cancer in Black patients is less common, but it is more deadly when it occurs. The disparity reflects delayed detection, misconceptions about risk, and a specialty historically centered on lighter skin. Black dermatologists are critical in addressing these gaps. Their presence strengthens mentorship pipelines, expands research focus, enhances patient trust, and improves diagnostic recognition across diverse skin tones. Diversifying dermatology is not symbolic reform. It is a clinical necessity. Early detection saves lives. Ensuring that all patients benefit equally from early detection requires systemic change. The statistics are clear and the stage gap is preventable. The question is whether the specialty will continue to prioritize reform at the scale required.

In this episode of Skin Anarchy, host Dr. Ekta Yadav sits down with Dr. Stephanie Culler, co-founder and CEO of Persephone Biosciences, to explore one of the most rapidly evolving areas of modern health science: the microbiome. From infant immune development to cancer treatment, the conversation reveals how microscopic organisms living in our bodies may play a far greater role in health than previously understood. From Cancer Research to Microbiome Innovation Dr. Culler’s path into microbiome science began with a deeply personal motivation. After losing both of her grandmothers to cancer as a teenager, she pursued a career in biomedical research with the goal of understanding disease at a molecular level. She completed her PhD at California Institute of Technology, focusing on gene therapy approaches for cancer treatment. Following her doctoral work, she moved to San Diego and began working in industrial biotechnology, where she developed expertise in microbial engineering and large-scale fermentation technologies. During this time, she became fascinated by the human microbiome—the trillions of microbes living primarily in the gastrointestinal tract—and its connection to immunity, metabolism, and disease prevention. Eight years ago, that curiosity led her to co-found Persephone Biosciences, a company dedicated to developing a technology platform capable of translating microbiome research into therapeutics and consumer health products. The Scientific Challenge: Understanding the Microbiome Despite the growing popularity of the term “microbiome,” Dr. Culler explains that scientific understanding of these microbial ecosystems is still relatively new. For years, researchers struggled to even identify what microbes existed in the gut. Nearly half of the microbiome was once considered “dark matter”—organisms that scientists knew existed but could not fully characterize. Today, advances in sequencing technology and computational biology have dramatically improved that picture. Scientists can now identify microbes in the gut with more than 99% accuracy. The next major challenge, however, lies in understanding how those microbes function. Knowing which bacteria are present is only the first step. Researchers must now determine how microbial communities interact with the immune system, metabolism, and disease pathways—and how those systems can be safely manipulated. Why the Infant Microbiome Matters One of the most striking areas of microbiome research involves early childhood development. According to Dr. Culler, the first years of life represent a critical window during which the immune system is trained by microbial exposure. During vaginal birth, infants inherit much of their initial microbiome from their mother. These microbes colonize the infant gut and begin interacting with the developing immune system. Breast milk plays an important role as well, containing complex sugars known as human milk oligosaccharides (HMOs). Interestingly, these compounds do not feed the baby directly—they feed beneficial gut bacteria. One of the most important microbes in this process is Bifidobacterium infantis, a species uniquely adapted to consume HMOs and dominate the infant gut ecosystem. Historically, this bacterium was extremely common in infants. However, modern research suggests it has become increasingly rare in Western populations. In Persephone’s large-scale “My Baby Biome” study, researchers found that only about 8% of infants in the United States carry sufficient levels of this critical bacterium—compared to estimates of 80–90% in previous generations. Modern Life and Microbial Disruption Dr. Culler points to several factors that may contribute to this shift. Antibiotic use, C-section deliveries, formula feeding, and modern dietary patterns can all influence the development of the infant microbiome. These changes may have unintended consequences. Research suggests that babies lacking key microbial species may face a higher risk of immune-related conditions such as eczema, asthma, and food allergies—collectively known as atopic diseases. The microbiome plays a central role in immune training during infancy. When the right microbial signals are missing, the immune system may develop improperly, increasing the likelihood of inflammatory or allergic conditions later in life. This growing body of research has led scientists to reconsider when preventive health interventions should begin—not in adulthood, but potentially during the earliest stages of life. A Precision Approach to Microbiome Restoration To address this challenge, Persephone Biosciences has been developing microbiome-based solutions designed specifically for infants and toddlers. Using strains isolated during their large-scale microbiome study, the company formulated a product that reintroduces key species of Bifidobacterium, including B. infantis, B. longum, and B. breve. The formulation also includes nutrients that support the growth of these bacteria, mimicking the relationship between breast milk and the infant microbiome. Dr. Culler describes this approach as a form of precision microbiome medicine—restoring missing microbial components in order to support normal immune development. Early studies have demonstrated safety and the ability of these bacteria to successfully colonize the infant gut, with future research planned to investigate potential benefits for conditions such as eczema and food allergies. The Microbiome and Cancer Therapy Beyond infant health, the microbiome is also emerging as a critical factor in cancer treatment. Over the past decade, researchers have discovered that gut bacteria can influence how patients respond to immunotherapy drugs. Checkpoint inhibitor therapies, such as Keytruda, work by enabling the immune system to recognize and attack cancer cells. While these therapies have revolutionized oncology, they do not work for every patient. Studies have shown that patients with a diverse and balanced microbiome respond significantly better to immunotherapy than those with disrupted microbial ecosystems. In some experiments, transferring microbiota from healthy individuals into cancer patients—through fecal microbiota transplantation—has improved treatment responses. This discovery has opened an entirely new field of research exploring how microbiome therapeutics could enhance cancer treatments and improve outcomes. A New Era of Preventive Health Throughout the conversation, Dr. Culler emphasizes that microbiome science is still in its early stages. However, the evidence already suggests that microbial ecosystems play a central role in human health—from infancy through adulthood. As researchers continue to uncover the connections between microbes, immunity, and disease, the future of medicine may shift toward earlier intervention and prevention. Understanding and supporting the microbiome could become a foundational part of healthcare. For Dr. Culler and her team, the goal is not just to study these microbial systems—but to translate that knowledge into clinically validated tools that improve health outcomes. Listen to the full episode of Skin Anarchy to hear Dr. Stephanie Culler break down the science behind the microbiome, early immune development, and how microbiome-based therapeutics could reshape the future of medicine.

Skin Anarchy

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