Can An Online Derm Take The Place Of A Real Derm? We Found Out

Illustrated by Elliot Salazar.
As a beauty writer, I can't possibly count the number of times I've cheerily encouraged readers to see a dermatologist — as though it's as easy and affordable as swinging down to the corner store. In actuality, many counties in the U.S. don't have a single dermatologist, and if you are lucky enough to be surrounded by skin-saving docs, getting an appointment can take months. Even then, a routine visit can cost a few hundred dollars. With insurance.

But, in the past year or so, a number of online dermatology services have popped up, offering people the opportunity to have their skin woes diagnosed by bona fide doctors. The idea is that through telemedicine, people can receive effective treatment and prescriptions without the expense or difficulty of an in-office visit.

It's an intriguing concept, but can a virtual consultation be as good as — or even better than — an IRL dermatologist visit? This is the question my editor posed to me. Would I, she asked, try out a new service called YoDerm, to see what the online doctor recommends? And then, would I go see a dermatologist in person to see what she advised? Fortunately for my editor, my chin looked like a relief map of a volcano range. I was Sergeant Zitface, reporting for duty.

A lot of women in their 30s are like me, losing the war against hormonal acne. Blackheads and whiteheads are rinky-dink stuff to me — getting those under control is no problem. But, for those tender monthly cysts, I've tried topicals, antibiotics, LED lights, dietary changes — almost everything except Accutane, the side-effect profile of which scares me. Naturally, I was excited to have not one, but two dermatologists weigh in on my pizza face. Total pimple Thunderdome.

I set up an account on YoDerm, which charges $59 for an online consultation; a dermatologist would review my photographs and medical history, then phone in a prescription to my neighborhood pharmacy. Easy enough. To start, I dutifully snapped camera-phone photos of my makeup-free face. You know how with most selfies, the goal is to get the most flattering angle? Instead, I did my best to highlight my chin zits while attempting to smize. With any luck, my photos would say, "I'm overjoyed to have hormonal acne."      
Illustrated by Elliot Salazar.
Then, it was time to fill out the medical file. If you've been fighting acne for two decades, listing failed treatments is a little depressing: tretinoin, Differin, clindamycin, doxycycline, Aczone, Finacea, Clenia, Yasmin, Lo Loestrin Fe, benzoyl peroxide, salicylic acid, peels. (I knew I was still forgetting something.) Each treatment entry required my feedback. How long did I use it? How effective was it? How tolerable was it? If not tolerable, why not?

I typed in a few other notes that might be helpful: dairy triggers cysts for me, I might want to be pregnant in a year or two, and oral antibiotics had not sat well with me. Beyond that, I noted my preference for a mild over aggressive treatment, entered my skin type ("normal," since I have combination skin), and confirmed that my medical insurance covers prescriptions. Confident that I'd filled out everything to the best of my abilities, I submitted my profile. Now, all I had to do was wait.

In the meantime, it was time to see a dermatologist. The offices of Dendy Engelman, MD, a board-certified dermatologic surgeon in Midtown Manhattan, are stylish and spacious. After I filled out forms about my skin concerns and medical history, a nurse escorted me to a small treatment room. She asked about my acne — where breakouts happen, which medications I've tried, whether pimples pop up around my period — but, she also asked when my last mole check was, and whether any family members have had skin cancer. Thorough, I thought.

A few minutes later, Dr. Engelman arrived, her air both warm and efficient. Unsurprisingly, she looked as though she'd never had so much as a clogged pore in her life, but she responded to my acne woes with empathy. "I break out in cysts if I eat dairy," I told her. "Giant, cheesy cysts that stick around for months."

"Some people do," she said. "It's good that you're aware of that trigger. What products are you using on your skin now?" I listed them: Ursa Major face wash, Skinceuticals CE Ferulic in the morning, Skinceuticals B5 gel morning and night, SPF 30 every day, and Skin Salvation hydrating cream. I also mentioned that since using Biologique Recherche Lotion P50, I'd had hardly any clogged pores — but, nothing was helping with the monthly hormonal breakouts.      
Illustrated by Elliot Salazar.
Dr. Engelman took notes as I spoke. "What did you think of Aczone?" she asked, referring to the topical anti-inflammatory.  

I shrugged. "Enh. I used it for about six months, and it kept my pores clear, but it didn't do anything for" — I gestured at my chin — "this kind of stuff."

"You know," Dr. Engelman said, "people either love Aczone, and it works wonders for them, or they have exactly the reaction you did. So, here's what I think we should do."

She laid out a treatment plan I hadn't tried. I was to use Epiduo, a topical combination of benzoyl peroxide and adapalene, to combat bacteria and keep pores from clogging. At the same time, I would start taking 50 mg daily of spironolactone, an oral anti-androgen drug that would help keep my hormonal acne in check. Because spiro can elevate potassium levels in some cases, I'd need to have somewhat regular blood work done to make sure things stayed copacetic. Dr. Engelman wrote a prescription for the blood work and medications, and then sent me on my way with some Epiduo samples and instructions to have my potassium checked in a month. I left feeling positive, even hopeful — sure, the blood stuff was an annoying task, but if this worked, it would be worth it.

The next day, I had a message from Aimee Paik, MD, my YoDerm doctor. Her diagnosis: Acne wasn't the problem. 

Say what?

"It looks like you have rosacea, which is a skin condition where people tend to get red easily and get acne lesions on the central areas of the face," she wrote. "I would like to prescribe you Finacea" — a topical with azelaic acid — "again, which is effective for rosacea and is also a safe treatment for acne while pregnant or trying to conceive." She also prescribed Ampicillin, an antibiotic to reduce inflammation; and Rosanil, a twice-daily sulfur wash.

Two dermatologists, two different diagnoses, two treatment plans: That doesn't mean one is right and one is wrong. Instead, it highlights the incredible challenges involved in trying to address acne. Basically, acne is crazy-complex, which is why it's unlikely for different dermatologists to give the same patient the exact same professional opinion. The things that trigger one person's breakouts might do nothing for another acne-prone person, which is why there's no silver bullet that can zap zits on every person, every time. Nope, it's a lot of trial-and-error.

On that note, since I only have one face, I couldn't test out both doctors' recommendations. Although Dr. Paik's diagnosis of rosacea was intriguing, I felt strongly that my breakouts were hormonal, since my acne got worse toward the end of my cycle. It seemed wise to try spironolactone under Dr. Engelman's watch, and if things didn't improve within six months or so, I could always try the rosacea plan. Keep in mind that I've seen over 20 derms about my acne, but only one other said I have mild rosacea and prescribed the same Rx. (It didn't help.)

If you want to know which method is better, here's the answer. Not to be coy or noncommittal, but it truly depends on your situation. If getting into a derm's office is easy and you have insurance, you may prefer that kind of face time. But, if you want to get a doctor's advice within a couple of days or you've never tried a prescription acne medication, YoDerm is a reasonably priced way to go. And hey, you can always try both — because as everyone says, it's always smart to get a second opinion.      

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