I spent $4,200 at the dermatologist in 2024 across eight visits. The menu was, by the derm's design, a la carte. The Botox was $15 per unit. The filler was $850 per syringe. The chemical peel was $200-$500. The laser was $400-$1,500 per session. The package deals — three Fraxel sessions for $1,200, five chemical peels for $1,000 — were, by my standard, the actual product.

The dermatologist's office is, in 2026, a restaurant with a medical license. The "restaurant" part is the menu, the upsell, the "package" deal, the take-home product. The "medical license" part is the consultation fee, the procedure room, the medical billing.

Below is the menu, with prices, as I encountered it in 2024. I have changed my mind about several things I used to believe about dermatology, most of them things I learned at the front desk. I have opinions on what to skip. There is a brief history of how the dermatologist's office went from a $40 insurance-covered acne visit in 1970 to a $4,200-a-year aesthetic practice in 2026. And there is, at the end, an honest summary — because anyone who tells you the dermatologist's office is a medical office has not, in fact, looked at the menu.

The list

1. The consultation fee, $550-$700. The dermatology consultation in Manhattan, in 2024, costs $550-$700. Dr. Dendy Engelman (Upper East Side) charges $700. Dr. Amy Wechsler (Upper West Side) charges $600. Dr. Marnie Nussbaum (Midtown) charges $550. The consultation is, by the derm's design, 30-45 minutes. The consultation is, by the derm's standard, "a comprehensive skin assessment." The consultation is, by my standard, "the upsell." The consultation always ends with a product recommendation, a procedure recommendation, and a package deal offer. The package deal offer is, by my standard, the actual product.

2. Botox, $15/unit ($300-$600 per session). Botox (onabotulinumtoxinA) was FDA-approved for cosmetic use in 2002. The average session, in 2024, uses 20-40 units. The price per unit, in 2024 Manhattan, is $15-$20. The average session cost is $300-$800. The session takes 15-20 minutes. The session lasts, by my standard, 3-4 months. The cost per year, for three sessions, is $900-$2,400. The American Society of Plastic Surgeons (ASPS) reported 1.6 million Botox procedures in 2023, making Botox the most popular minimally invasive cosmetic procedure in the US.

3. Filler (Juvederm, Restylane), $800-$1,200 per syringe. Hyaluronic acid fillers were FDA-approved for cosmetic use in 2003. The average session, in 2024, uses 1-2 syringes. The price per syringe is $800-$1,200. The average session cost is $800-$2,400. The session takes 30-45 minutes. The filler lasts, by my standard, 9-12 months. The cost per year, for one session, is $800-$2,400. ASPS reported $5.4 billion spent on fillers in 2023, making fillers the second-largest minimally invasive cosmetic category.

4. Chemical peel, $200-$500 per session. Chemical peels use glycolic acid, trichloroacetic acid (TCA), or phenol to remove the outer layers of skin. The light peel (glycolic, 20-50%) costs $150-$300. The medium peel (TCA, 30-50%) costs $300-$500. The deep peel (phenol) costs $1,000-$3,000. The average session cost is $300. The session takes 20-30 minutes. The peel requires, by my standard, 5-7 days of downtime. The cost per year, for four sessions, is $1,200-$2,000.

5. Laser (Fraxel, IPL), $400-$1,500 per session. Laser treatments use focused light to resurface the skin. Fraxel (fractional CO2 laser) costs $1,000-$1,500 per session. IPL (intense pulsed light) costs $400-$600 per session. The average session cost is $800. The session takes 30-60 minutes. The laser requires, by my standard, 3-7 days of downtime. The cost per year, for three sessions, is $1,200-$4,500.

6. Microneedling, $300-$500 per session. Microneedling uses fine needles to create controlled micro-injuries in the skin. The session cost, in 2024 Manhattan, is $300-$500. The session takes 30 minutes. The microneedling requires, by my standard, 1-2 days of redness. The cost per year, for four sessions, is $1,200-$2,000.

7. The take-home product, $185-$400 per recommendation. Every dermatology visit, in my experience, ends with a product recommendation. The recommended product is, by the derm's design, sold at the front desk. The recommended product is, by my standard, marked up 30-50% over retail. Dr. Dennis Gross Peel Pads ($88 at Sephora, $115 at the derm). SkinMedica TNS Advanced+ Serum ($281 at the derm, $220 at the SkinMedica website). Augustinus Bader The Cream ($165 at Sephora, $200 at the derm). The derm's take-home product is, by my standard, the highest-margin item on the menu.

8. The "package" deal, 20-30% off. The "package" deal is, by the derm's design, the upsell mechanism. Three Fraxel sessions for $3,600 ($1,200 each) becomes three for $3,000 ($1,000 each). Five chemical peels for $1,500 ($300 each) becomes five for $1,000 ($200 each). The package deal is, by my standard, "the actual product." The package deal is, by every measure, the way the derm locks in $1,000-$4,000 of revenue per patient per year.

That is eight items on the dermatology menu. I spent $4,200 in 2024 across eight visits. The breakdown was approximately: $1,800 on Botox (3 sessions), $1,200 on filler (1 session), $800 on chemical peel (1 session), and $400 on the take-home product.

What I have changed my mind about

A few beliefs I held in 2018, that the last six years have killed.

I used to think the dermatologist's office was a medical office. The dermatologist's office is, by every measure, a hybrid medical-aesthetic practice. The medical part is the consultation fee, the prescription, the biopsy. The aesthetic part is the menu — Botox, filler, laser, peel, microneedling, take-home product. The aesthetic part is, by my standard, 80% of the revenue. The aesthetic part is, by my standard, what the office actually sells.

I used to think Botox was dangerous. Botox is, by every dermatologist I have asked, the most studied cosmetic procedure in history. Botox is, by my standard, very safe in the hands of a board-certified dermatologist. Botox is, by my standard, less safe in the hands of a med-spa, a "Botox party," or a nurse injector working from a strip-mall office. The danger is, by my standard, not the Botox. The danger is the injector.

I used to think filler was permanent. Filler is, by my standard, not permanent. Hyaluronic acid filler (Juvederm, Restylane) lasts, by my standard, 9-12 months. Calcium hydroxylapatite filler (Radiesse) lasts, by my standard, 12-18 months. Poly-L-lactic acid filler (Sculptra) lasts, by my standard, 2+ years. The "permanent" filler is, by my standard, not filler. The "permanent" filler is, by my standard, a different category of product.

I used to think the take-home product was the best available. The take-home product is, by my standard, mostly the same product available elsewhere. The take-home product is, by the derm's design, sold at the front desk for the patient's convenience. The take-home product is, by my standard, marked up 30-50% over retail. Skip the front-desk product. Buy the same product elsewhere.

I used to think the package deal saved money. The package deal saves, by my standard, 20-30% on the listed price. The package deal also, by my standard, commits me to $1,000-$4,000 of spend over the next 12 months. The package deal is, by my standard, the most efficient way to lock in future revenue. Skip the package deal. Pay per session.

What to skip at the dermatologist's office

If I were advising a friend who was about to walk into a dermatology office in 2026, I would tell them to skip these things.

The first consultation. The first consultation is, by my standard, the most expensive "first date" in personal finance. The first consultation is, by the derm's design, the upsell mechanism. Skip the first consultation. Go directly to the procedure you want, if you know what you want.

The take-home product. The take-home product is, by my standard, the same product available elsewhere. The take-home product is, by my standard, marked up 30-50% over retail. Skip the front-desk product. Buy the same product at Sephora, Amazon, or the brand's website.

The "package" deal. The package deal saves, by my standard, 20-30%. The package deal also, by my standard, commits to future spend. The package deal is, by the derm's design, a way to lock in revenue. Skip the package deal. Pay per session.

The new procedure you have never heard of. The new procedure — "PRP facial," "microneedling with radiofrequency," "Halo laser," "Moxi laser" — is, by every dermatologist I have asked, "the procedure the practice is trying to move this quarter." The new procedure is, by my standard, the procedure with the highest commission for the injector. Skip the new procedure. Stick to the established procedures.

The med-spa partnership. The med-spa partnership — the dermatology office that refers you to a med-spa for laser, and the med-spa that refers you to the dermatology office for Botox — is, by my standard, a commission arrangement. The med-spa partnership is, by my standard, a 10-20% commission on every referral. Skip the partnership. Find your own providers.

The "comprehensive" treatment plan. The comprehensive treatment plan — Botox + filler + laser + peel + take-home product — is, by my standard, $10,000-$15,000 per year. The comprehensive treatment plan is, by the derm's design, the maximum upsell. Skip the comprehensive plan. Pick one or two procedures per year.

A brief history

The dermatologist's office is, by every measure, a 20th-century medical specialty. Dermatology was established as a medical specialty in the late 19th century, with the American Dermatological Association founded in 1877. The early dermatology practices focused on skin disease — psoriasis, eczema, acne, skin cancer.

The mid-century dermatology practice was, by 1960s standards, mostly insurance-covered. The standard visit was, in 1960s dollars, $10-$25. The procedures were biopsies, excisions, and topical prescriptions. The aesthetic procedures — chemical peels, dermabrasion — existed but were, by 1980s standards, rare and expensive.

The 1990s brought the aesthetic dermatology boom. The 1992 FDA approval of tretinoin (Retin-A) for photoaging was, by every dermatologist I have asked, the inflection point. The 1996 launch of Botox for cosmetic use (full FDA approval 2002) was, by every measure, the second inflection point. The 2000s brought the laser boom — Fraxel (2004), IPL (2000s), CO2 laser (1990s, refined 2000s).

The 2010s brought the social-media boom. Instagram (2010) and the influencer economy made aesthetic dermatology aspirational. The 2010s also brought the med-spa boom — the strip-mall "medical spa" offering Botox at $11/unit, filler at $500/syringe, with nurse injectors rather than board-certified dermatologists.

The 2020s brought the consolidation. The US dermatology market, in 2024, was estimated at $20 billion. The aesthetic procedure market (Botox, filler, laser, energy devices) was, by Grand View Research, the fastest-growing segment at +18% YoY. The med-spa count, in 2024, was estimated at 7,500+ in the US (per AmSpa). The dermatologist's office is, in 2026, a hybrid medical-aesthetic practice. The aesthetic part is, in 2026, 70-80% of the revenue.

The honest summary

The dermatologist's office is, in the end, a restaurant with a medical license. The menu is Botox, filler, laser, peel, take-home product. The upsell is the package deal. The product is the front-desk product. The whole thing is, by my standard, a $4,200-a-year commitment if you let it be.

What works for me: Botox three times a year ($1,800), one filler session a year ($1,200), and a $30 chemical peel at a medi-spa rather than the derm's office. The total is $3,030, not $4,200. The total is, by my standard, the minimum effective dose of dermatology.

What does not work for me, and may not work for you: the "comprehensive" treatment plan. The comprehensive plan is, by my standard, the maximum upsell. The comprehensive plan is, by every measure, the way the practice maximizes revenue. The honest summary is, in the end, this: the office is selling a menu. The menu, when ordered carefully, does not have to cost $4,200.

Six years in, my skin is, by every measurement that matters, better than it was when I started. I have spent, in those six years, approximately $22,000 on dermatology. I could have spent approximately $30,000 and had the same skin. The math is, by any honest accounting, embarrassing. The math is also, in the end, the only thing that matters.