March 11, 2022 -- A young woman is having her lip swabbed with an unknown substance, smiling, on the TikTok video. Seconds later, another young woman, wearing gloves, pushes a hyaluron pen, a needle-free injector for dermal fillers, against the first woman's lips.
In the next cut, the first woman is smiling, happy. "My first syringe down and already 1,000x more confident," the caption reads.
That video is one of thousands showing hyaluron pen use on TikTok. The pens are sold online and are not FDA-approved. In October, the agency warned that using the devices could cause bleeding, infection, allergic reactions, blood vessel blockages that could result in blindness or a stroke, and other injuries.
The warning has not stopped many TikTok users, who also promote all sorts of skin and aesthetic products and procedures, a large number unproven, unapproved, or ill-advised.
As TikTok has become one of the most widely used social media platforms, millions of mostly teenagers regularly log on for skin care advice, which, more often than not, comes from "skinfluencers," aestheticians, and others who are not dermatologists.
The suggested "hacks" can be harmless or ineffective, but they also can be misleading, fraudulent, or even dangerous.
The potential for harm led California Attorney General Rob Bonta -- along with Democratic and Republican attorneys general in other states -- to launch a nationwide investigation of the platform. Many children “feel like they need to measure up to the filtered versions of reality that they see on their screens,” Bonta said in early March when he announced the inquiry.
Skinfluencers Take the Lead
Visitors watch videos that run from 15 seconds to up to 3 minutes. They can follow their favorite TikTokkers, search for people or hashtags, or click on content the platform recommends based on algorithms.
Yarbro is seen as a no-nonsense debunker of skin care myths, as is British influencer James Welsh (@james_s_welsh), who has 128,000 followers.
@Yayayayoung, a young, bald Asian man, (1.6 million followers) offers product tips in a comedic vein.
To Sandra Lee, MD, the popularity of people who aren’t doctors is easy to explain.
"You have to think about the fact that a lot of people can't see dermatologists -- they don't have the money, they don't have the time to travel there, they don't have health insurance, or they're scared of doctors, so they're willing to try to find an answer. And one of the easiest ways, one of the more entertaining ways to get information, is on social media," she says.
Lee is in private practice in Upland, CA, but is better known as "Dr. Pimple Popper," through her television show of the same name and her social media accounts, including on TikTok, where she has 15.4 million followers.
"We're all looking for that no-down-time, no-expense, no-lines, no-wrinkles, stay-young-forever, magic bullet," she says.
Adam Friedman, MD, a professor and chair of dermatology at George Washington University in Washington, DC, agreed that people are looking for a quick fix. They don't want to wait 12 weeks for an acne medication or 16 weeks for a biologic drug to work, he says. "They want something simple, easy, do-it-yourself," and "natural."
Laypeople are the dominant producers of dermatology content and have the most views, research shows.
Researchers at the Feinberg School of Medicine at Northwestern University looked at hashtags for the top 10 dermatologic diagnoses and procedures and analyzed the content of the first 40 TikTok videos in each category. About half the videos were produced by an individual, and 39% by a health care practitioner, according to the study, published in September in the International Journal of Women's Dermatology.
Viewership was highest for videos by laypeople, followed by those from business or industry accounts. Videos by health care professionals received only 18% of the views.
The researchers noted that the most liked and most viewed posts were related to #skincare, but that dermatologists produced only 2.5% of the #skincare videos.
Dermatologists Take to TikTok
Some dermatologists have started their own TikTok accounts, seeking both to counteract misinformation and provide education.
Muneeb Shah, DO, a dermatology resident at Atlantic Dermatology in Wilmington, NC -- known to his 13.4 million TikTok followers as @dermdoctor -- has become one of the top influencers on the platform. In a year-end wrap, TikTok put Shah at No. 7 on its top creators list for 2021.
Shah says that TikTok is a good tool for reaching patients who might not otherwise interact with dermatologists. He tells the story of a person who came into his office with the idea that they had hidradenitis suppurativa, a condition that causes painful bumps under the skin that can get infected.
The person had self-diagnosed after seeing one of Shah's TikTok videos on the condition. It was a pleasant surprise, Shah says. People with hidradenitis suppurativa often avoid treatment. The condition is underdiagnosed and improperly treated, despite an American Academy of Dermatology awareness campaign, he says.
Another dermatology resident, Chris Tomassian, MD, uses his TikTok account to answer his 1.4 million followers’ questions about acne, retinol, and skin care products, to debunk myths, and urge sunscreen use.
Lee, the dermatologist known as “Dr. Pimple Popper,” says she prefers TikTok to Instagram, because TikTok's algorithms and its younger-skewing user base help her reach a more specific audience.
TikTok also celebrates the everyday -- someone doesn't have to be a celebrity to make something go viral, says Lee. And she believes that TikTok users are more accepting of average people with real problems, which helps when making a video about a skin condition.
Doris Day, MD, who goes by @drdorisday on TikTok, agrees with Lee. "There are so many creative ways you can convey information with it that's different than what you have on Instagram," says Day, who is in private practice in New York City. "It does really lend itself to getting points out super-fast."
Dermatologists on TikTok also say they like the "duets" and "stitch" features, which allow users to add on to an existing video, essentially chiming in or responding to what might have already been posted, in a side-by-side format.
Shah says he often duets videos that have questionable content. "A lot of times, if something is going really viral and it's not accurate, you'll have a response from me or one of the other doctors" within hours or days, he says.
Shah's duets are labeled with "DermDoctor Reacts" or "DermDoctor Explains." In one duet, with more than 2.8 million views, the upper half of the video is someone squeezing a blackhead, while Shah, wearing green scrubs in the bottom half of the screen, says over some hip-hop music: "This is just a blackhead. But once it gets to this point, they do need to be extracted because topical treatments won't help."
Lee, whose TikTok and other accounts capitalize on teens' obsession with popping pimples, has a duet in which she advised that although popping will leave scars, there are more ideal times to pop, if they must. The duet -- with Salt-N-Pepa’s “Push It” as the soundtrack” -- has at least 21 million views.
Sometimes a TikTok video effectively takes on a trend without being a duet. Nurse practitioner Uy Dam (@uy.np) has a video that demonstrates the dangers of hyaluron pens. He uses both a pen and a needle to inject fluid into a block of gelatin. The pen delivers a scattershot load of differing depths, while the needle is exact. It's visual, easy to understand, and has at least 1.3 million views.
TikTok Trends Gone Bad
Still, TikTok, like other forms of social media, is full of misinformation and false accounts, including people who claim to be doctors. "It's hard for the regular person, myself included, sometimes, to be able to root through that and find out whether something is real or not," Lee says.
Friedman of George Washington University says he's concerned about the lack of accountability. A doctor could lose their license for promoting an unproven cure, especially if it’s harmful. But for influencers, "there's no accountability for posting information that can actually hurt people," he says.
Friedman once had a patient with a rash, "almost like chemical burns to her underarms," he says. He found out that she saw a video "hack" that recommended using baking soda to stop excessive sweating, called hyperhidrosis. The patient used so much that it burned her skin, he says.
In 2020, do-it-yourself freckles -- with henna or sewing needles drenched with ink -- went viral. Tilly Whitfeld, a 21-year-old reality TV star on Australia's “Big Brother” show, told The New York Times that she tried it at home after seeing a TikTok video. She ordered brown tattoo ink online and later found out that it was contaminated with lead. Whitfeld developed an infection, temporary vision loss, and has permanent scarring.
She has since put out a cautionary TikTok video that's been viewed some 300,000 times.
TikTokkers have also flocked to the idea of using sunscreen to "contour" the face. Selected areas are left without sunscreen to burn or tan. In a duet, a plastic surgeon shakes his head as a young woman claims it works.
Scalp-popping -- a trend in which the hair is yanked so hard that it pulls a layer of tissue off the skull -- has been mostly shut down by TikTok. A search of "scalp popping" brings up the message, "Learn how to recognize harmful challenges and hoaxes."
At-home mole and skin tag removal, pimple-popping, and supposed acne cures such as drinking chlorophyll are all avidly documented and shared on TikTok.
Shah had a back-and-forth video dialogue with someone who had stubbed a toe and then drilled a hole into the nail to drain the hematoma. In a reaction video, Shah said it was likely to turn into an infection. When it did, the man revealed the infection in a video where he tagged Shah. He later posted a video at the podiatrist's office having his nail removed, again tagging Shah.
"I think that, pretty much, no procedure for skin is good to do at home," says Shah, who repeatedly admonishes against mole removal by someone who isn’t a doctor. He tells followers that "it's extremely dangerous -- not only is it going to cause scarring, but you are potentially discarding a cancerous lesion."
Unfortunately, most will not follow the advice, Shah says. That's especially true of pimple-popping. Aiming for the least harm, he suggests in some TikTok videos that poppers keep the area clean, wear gloves, and consult a doctor to get an antibiotic prescription.
Lee believes that lack of access to doctors, insurance, or money may play into how TikTok trends evolve. "Probably those people who injected their lips with this air gun thing, maybe they didn't have the money necessarily to get filler," she says.
Also, she notes, while TikTok may try to police its content, creators are pushed to be outrageous. "The more inflammatory your post is, the more engagement you get," she says.
Shah thinks TikTok is self-correcting. "If you're not being ethical or contradicting yourself, putting out information that's not accurate, people are going to catch on very quickly," he says. "The only value, the only currency you have on social media is the trust that you build with people that follow you."