Who Can Do What in a Med Spa?

November 14, 2019

As the new kid on the block, med spas are breaking the mold of the traditional medical practice model. The merging of medicine and day spa services has created a new industry with multiple governing authorities to regulate it and the varying roles within it.

Most med spas provide some combination of medical and aesthetic procedures – lasers, Botox, fillers, Kybella®, microneedling, microdermabrasion, dermaplaning, chemical peels, dermabrasion and CoolSculpting®. Often this menu of services blurs the line between medical and spa treatments. While these procedures are considered medical in most states, exemptions exist in others. For example, the cosmetology boards of certain states allow estheticians and cosmetologists to perform microdermabrasion and dermaplaning as long as the procedure does not penetrate the dermal layer of the skin. On the other hand, more restrictive state regulating boards limit esthetic and cosmetology practices to the topmost layer of the skin. This leads to the common question who can do what in a med spa?

The authority to administer medical aesthetic treatments follows a basic hierarchy:

  1. Physician;
  2. Nurse Practitioner (NP) and Physician Assistant (PA);
  3. Registered Nurse (RN), Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN); and
  4. Esthetician, Cosmetologist, and Unlicensed Personnel.


Physicians have the broadest authority and often fill the role of owner or medical director in med spas. The delegation of medical treatments to the rest of the staff falls under the supervision of these physicians, and sometimes NPs and PAs.

NPs and PAs

Certain states grant independent practice authority to NPs, and in those states physician delegation or supervision is not required. Independent practice NPs can provide medical procedures falling under their scope of practice. Where NPs due not have autonomy, state laws generally indicate the level of physician supervision required for both NPs and PAs. In most cases, NPs practice in collaboration with a physician. Depending on the state’s laws, collaboration commonly follows written protocols (i.e., a list of delegated medical tasks, restrictions or limitations, prescriptive authority and level of supervision). Similarly, PAs usually practice pursuant to a supervision or delegation agreement, addressing their scope of practice and any applicable restrictions.


The scope of practice of a RN is more limited and subject to stricter delegation and supervision than an NP or PA. Unless state law dictates otherwise, a qualified physician or independent practice NP may delegate medical tasks to RNs, as long as the procedure is within their scope of practice and competency has been verified. If required, written protocols are delineated and appropriate supervision provided. If state laws do not define the level of supervision, the delegating practitioner must use their professional judgement to identify and engage in it appropriately.

LPNs and LVNs

The scope of practice of LPNs/LVNs is more limited and subject to stricter delegation and supervision than an NP, PA or RN. State laws generally dictate the medical tasks that a qualified physician or independent practice NP can delegate to LPNs/LVNs, whether written protocols are required, and the appropriate level of supervision. Similar to RNs, if state laws do not define the level of supervision, the delegating practitioner must use professional judgement to identify and engage in it appropriately.

Estheticians and Cosmetologists

There is much confusion in the med spa world about what is considered licensed personnel. While estheticians and cosmetologists are licensed by cosmetology boards, they are considered unlicensed personnel by medical standards. These other licensees are generally permitted to perform spa procedures (facials, certain types of massages) that fall under their cosmetology licensure, but prohibited from doing anything requiring medical training.

Unlicensed Personnel

In addition to estheticians and cosmetologists, medical assistants (MAs) are considered unlicensed personnel for medical treatments and can perform treatments in med spas only as state law allows. With limited to no medical training, these staff members are generally not permitted to perform medical or invasive procedures. Even if state law allows delegation, it is often required that the delegating practitioner provide on-site, direct supervision during procedures. Delegation of medical treatments to unlicensed personnel must be approached with extreme caution.

From state to state, laws related to med spa treatments vary from the very detailed to the very sparse, leaving room for legal interpretation. If you have any questions or would like to know more about med spa compliance in your state, please schedule a consult at info@byrdadatto.com.

ByrdAdatto attorney Bala Mohan

Bala Mohan

From a young age Bala Mohan excelled in her biology and chemistry coursework, and she soon realized that her calling was to be a health care attorney.

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