Acne consultations; virtual 

Virtual Acne Consultations

Virtual acne consultations are designed to give patients a clear strategic pathway to manage acne. During this consultation I will cover all aspects of acne including home options such as topicals, skin care, diet & ancillary treatments such as LED sources, through to prescriptive medications for acne. The recommendations will be algorithm based & expressed as a probability of a program working for you as I take into consideration your clinical picture. 

Summary of virtual consultations for acne

This consultation covers all aspects of acne management including-

• Management options including topicals & oral agents 
• Appropriate skin care for acne prone skin 
• Scar mitigation strategies 
• Guide to any investigations required
• Cost for this service is $490, this includes a written report
• Acne scar revision consultations are not covered in the acne consultation process as this follows another management algorithm. More here. 

What is the aim of this consultation?

This virtual consultation is designed to guide patients from all around the world as to the most appropriate management options for acne. I do so without being involved in your management, namely I do not prescribe medications, but provide avenues for you to seek treatment. In some cases this can be with alteration of your skin care or diet, in other cases I may suggest specialist management by a dermatologist in your city. 

Do I do real time acne consultations?

No. My daily work is entirely procedural, namely I operate, laser, peel & inject. I do not get involved in prescriptive (medical dermatology). This enables me to concentrate on the things I love most- working with my hands. 

Virtual consultations are designed as a strategic pathway for patients & not a service to manage – treat acne. Why? Acne treatment is more complex than most patients realize. It can (& often) involves –

• Frequent review to see progress of treatments
• Access to dermatologists to discuss side effects of treatments
• Follow up for blood tests for some forms of medications
• Additional investigations for hormonal causes of acne

For a real time consultation with my colleagues, contact Cutis Dermatology in Brisbane. 

How do I know what is the best treatment for your type of acne?

An accurate treatment algorithm can be established based upon history & clinical photography. Here is how it works. 

1. Contact my administrator staff here. They will discuss payment options & tee up a time with you for a virtual consultation. 
2. I send you a questionnaire (programmed via branching algorithms). This covers your history. 
3. Attach clear photographs. A diagnosis is only as clear as your photos.
4. After reviewing the history & clinical photos, I will send you a report, in addition to a virtual consultation to cover the important points within the body of the report. 

What aspects of acne management will I cover?

The main pillars of acne management are-

1. 1. Washes, cleansers & moisturizers
   2. Topicals including over the counter skin care & prescription creams/gels
   3. Anti-inflammatory antibiotics
   4. Anti-hormonal medications
   5. Retinoids including Accutane 
   6. Lasers & LED therapy
   7. Chemical peels for acne
   8. Ancillary acne patches
   9. Evidence of dietary restrictions 

*Not all of these therapies will be covered in the virtual report as I will address the most appropriate treatments for your acne subtype. 

To what extent do I cover over the counter acne skin care?

Specifics will be provided, including any product recommendations for washes, moisturisers, retinol-retinoids if applicable. 

*For some cases of acne, including hormonal acne, picking acne, cystic & scarring acne, the chances of skin care working is low. In this case I may provide you with advice, but clearly state the optimal treatments for your pattern of acne. 

Will I provide a solution for acne scarring during this virtual consultation?

Very briefly. Why? Because you need to put the horse before the cart. Remember, the biggest predictive factor for acne scarring is the time taken to effective management. It is not the time taken to start therapy, or to have a go at a novel treatment. It is the time taken to place acne in remission. The virtual consultation however will provide advice for acne scar mitigation (prevention). This is different from an acne scar revision virtual consultation as it follows a vastly different approach to acne management. 

How will the report be formulated?

The report will be sent prior to the virtual consultation. It will cover –

• Appropriate washes & skin care
• Acne treatment strategic pathway
• Additional aspects that I deem important. This includes possible investigations by different specialties 
• Scar mitigation strategies (this is different from acne scar treatment plans)

Options pertaining to your acne will be given with an allocated projected percentage of success. 

What is the cost of a virtual consultation?

$490. This includes a written report based upon your history & photographs. 

Note: I do not treat-manage acne in my practice as this is my procedural time. The only time I provide acne consultations is via this virtual service. 

Is it worth it?

This service is designed to give you a pathway to treating your acne, without prejudice or conflict of interest. For some, it may represent great value as an unbiased report, or as a second opinion. For others who would like to approach acne as retail therapy, there is very little, if any, value in this service. Your call. 

How accurate is this report?

It is only as accurate as your history (what you tell me) & the photos that you provide. 

What are the limitations of this virtual consultation?

The report is only as accurate as your history & clinical photography. By providing clear photos, I can increase my accuracy of diagnosing your acne subtype & hence provide a more accurate treatment report. 

Additionally, treatment plans are based upon statistics; I give a chance percentage based upon your clinical findings & history.  In some cases (as dedicated by chances), your real time algorithm may differ. 

What clinical aspects will I consider when formulating an acne treatment plan?

The most important aspect to consider is if your acne is potentially scarring or non-scarring. If you have a high chance of acne scarring, I will advise you to seek professional advice from a board certified dermatologist. Remember the most predictive factor for acne scarring is the time taken to achieve effective treatment & remission. Other aspects I consider include-

• Acne lesion type; eg. cystic acne, picking acne
• Extent of acne; eg. trunk-chest-back-neck-jawline
• Skin color or ethnicity (more on that later) 
• The presence of acne scarring
• The presence of any stigmata pertaining to hormonal acne/PCOS acne 

What historical aspects will I consider when formulating a plan to treat acne?

I take into consideration the following –

• The emotional aspects of acne, including the impact on your life. 
• Your past treatments; including failures & successes
• The duration of acne 
• Any family history of acne or acne scarring
• Any medical issues such as depression & mood swings
• Any conception plans 
• For female patients, I take into consideration conception plans, hormonal flares & cyclical changes 
• Your access to medical therapy 
• Your willingness to undertake medical prescriptive therapy or alternative therapies

*I may not place much emphasis on your Google research, however I will validate your points if they are appropriate.  

What is the term ‘acne treatment ladder’ & how does this apply to a virtual consultation?

Treatments are recommended based upon your ‘subset’ of acne & your history. From there I formulate a management plan that may involve creams, chemical peels, tablets or lasers. 

For mild cases a more conservative approach is given, whilst for scarring acne (or chronic acne), I may recommend other treatments such as Accutane. 

What is my acne treatment algorithm when dealing with skin of color or ethnic patients?

Acne treatments in darker skin types follow a different approach because ethnic patients are more prone to post inflammatory hyperpigmentation, or dark acne scars. Management strategies include – 

• More aggressive treatments to place acne in remission faster
• Prevention or mitigation of pigmented scars
• Treatment of dark hyperpigmentation (best with lasers & topicals)

What is my treatment algorithm when it comes to dealing with hormonal acne?

Here is an important concept to understand- most cases of acne are ‘hormonal’. This means that your hormone levels are normal, but your oil glands are sensitive to normal hormones. There are 3  exception to this rule –

1. PCOS, which is super common, affecting one in six Australian women. 
2. Hormonal medications; namely testosterone & androgens.
3. Rare tumors that produce prolactin, testosterone, dehydroandrosterone etc.   

For hormonal acne, topicals may (rarely) be effective. This group of patients may benefit from systemic therapy (tablets). 

What types of acne are hard to treat; & how to best manage?

Some types of acne are harder to treat than others & require a multispecialty team. They include-

• Hormonal acne such as PCOS associated with acne
• Picking acne or OCD associated acne
• Acne-made worse with medications. This subgroup will require titration of medications, example include lithium associated acne or acne due to androgens. 

What are submarine comedones or tiny acne cysts & why are these difficult to diagnose on virtual consultations?

These lesions are difficult to diagnose on virtual consultations as they lie deep under the skin. These cysts are not true cysts, but represent closed comedones (white heads) that are most visible with stretching of the skin, or pressure from underneath the skin. As they occur around the chin-mouth area, pushing your tongue against the skin may give a better picture. 

Submarine comedones are more resistant to treatment, including Accutane therapy. The fastest way to remove these is to use an erbium or CO2 laser with a 1 mm spot size. This is known as the drill technique. Other methods include RF insulated needling or a pin-point hyfrecator. Dermatologists in third world countries may use a needle with a comedone extractor.

Do I give dietary advice when it comes to acne?

Yes, but it only takes 30 seconds to summarize an anti-acne diet. In short-

• Eat less sugar (avoid if possible)
• Don’t consume dairy products
• Don’t consume processed foods (anything in a packet, bar nuts)
• Eat organic food over hormonally fed meat-fish

For more click here. 

When do I advise acne patches?

Acne patches are the most cost effective method to treat picking acne. They are invaluable to mitigate acne scarring due to habitual picking. Patches are also advocated for those who suffer the odd break out. My patch of choice? Simple hydrocolloid patches. They cost between 5 to 25 cents each & are available at most pharmacies. 

More on acne patches & other ways to treat acne at home. 

What solutions are there for recurrent acne?

Even if you have had a course of Accutane (or multiple courses), there are alternatives for recurrent acne. The question is how effective are they? For mild cases topical alternatives can be effective. In some cases antihormone therapy is advocated, whilst for more resistant cases, multiple treatments of Accutane may be beneficial. I approach the advice on a case to case basis. 

How do I rate Kleresca, AviClear & lasers for acne?

These treatments from the non-pharmacological method of treating acne, & represent the commercial side of acne therapy. They are a great alternative for patients (consumers) who are seeking-

• Novel treatments (latest trending skin care procedures)
• A non-prescriptive way to address acne with much less side effects compared to traditional methods such as antibiotics & Accutane. 

Kleresca is essentially PDT or photodynamic therapy. The remission rate varies between 20 to 60% depending on the studies. 

Lasers are also used to treat acne, with the very latest laser, AviClear,  showing a greater than 50% reduction in acne lesions after 3 months of laser therapy. 80% of patients can respond to this treatment with higher responses (87%) at 6 months. The long term benefits have not been ascertained beyond 6 months. 

Do I cover natural acne treatments in the consultation?

Yes, in some cases I will cover the fluffy stuff, however if you are after advice on what brand of witch hazel or tea tree oil to buy, you may be better served on a naturopathic forum. I am not against natural acne remedies; hence why you will find a dearth of information on this site where I discuss the role of zinc, dietary supplements & dietary recommendations. If you are after a natural avenue, I suggest following this route before you make an appointment.

A naturopathic approach can be highly effective in a minority of patients, especially when combined with –

• Dietary restrictions
• Supplements such as probiotics, zinc & omega fatty acids
• Fairy dust acne treatments such as botanicals
• Meditation to destress
• Good sleep patterns to regulate cortisol 
• Good make up & skin care products
• Natural phototherapy (at the expense of photoaging) 

More on natural ways to treat acne. 

Do I advocate LED acne masks?

It depends on the clinical scenario. If you have hormonal acne & or scarring acne, you are best seen by a dermatologist. Masks are more useful for pimples- acne in the younger age group, as compared to adult acne, which has a more significant hormonal input. 

LED light, especially in the blue spectrum is most efficient at killing c.acnes bacteria, however it can worsen pigmentation, especially in darker – ethnic skin types. 

If you are considering LED masks, my suggestion is to combine it with topical treatments; namely Differin or other prescription retinoids. Collagen remodeling & stimulation with LEDs is minimal, as compared to lasers & bio remodeling injectables. Regardless, placebo can be useful. 

Summary of LEDs for home use

• Best for non-hormonal acne
• Blue, red & yellow light wavelengths are used
• Darker skin types should avoid blue light (HEV spectrum = pigmentation)
• Combine with topicals
• Document progress, see a dermatologist if no better in 10 weeks

Why is photographic documentation so important when treating acne?

Photos produce an objective insight into the efficacy of acne treatments. For an unbiased real world assessment of how you are tracking, ignore the subjective viewpoints (eg. I feel like my acne is getting better, or worse), concentrate on the objective assessment – namely how many acne lesions have you got over a specific period of time. The way to get this information is to count the number of papules, cysts, blackheads & pimples. 

For a treatment that is considered as ‘good’ or clinically efficacious, it should reduce acne lesion count by 25% at 16 weeks, pushing to 50% reduction in acne lesion count at 26 weeks. 

If it is less than this, it’s probably not working. 

Davin’s take on virtual consultations

This service is designed to provide patients a concise & clear pathway to manage acne based upon your clinical picture & history. It does so without conflict of interest- namely I provide a report without being involved in your treatment itself. 

The report will provide a treatment plan based upon a Gaussian curve, namely a statistical probability that the treatment plan may work, or conversely may not. For example if you have severe cystic acne, the chances of Accutane working is approximately 92%. The 8% failure rate represents the individuals who can not tolerate the drug. In contrast, a topical such as retinol may only have a 3% probability of working in the context of cystic acne. Obviously the recommendations will be based upon a risk benefit ratio of each treatment modality. 

Why don’t I get involved in prescriptions for acne? It is because my interests & allocated time lies in procedural dermatology- namely I cut, laser, deep peel or inject. Acne treatment per say is involved & you do need to tee up with a medical dermatologist for management. Not infrequently, blood tests need to be ordered, reviewed & repeated. This is especially important for hormonal acne as well as patients who are on oral retinoids. 

A significant percentage of patients I see on virtual consultations present with recurrent acne, despite having completed a course of Accutane (or even several courses). This subgroup of patients can benefit from topical therapy (if mild), LED home therapy (if indicated) or more involved treatments if recurrence is extensive, cystic or scarring. 

What is the role of diet & supplements & why do I advocate them for the treatment of acne?

Diet plays a role in most, but not all cases of acne, hence why I advocate an acne diet in all cases, including mild cases, hormonal acne through to cystic acne. The two hurdles regarding  dietary changes are- 

1. You can not cheat with an acne diet. Unlike a caloric deficit diet where you can restrict your calories, hence eat in moderation, an acne diet is ‘all or nothing.’ For weight loss diet you can be great 6 days a week, but may have a cheat day. You can not do this for acne as cheating will often lead to a flare up of acne. Realistically, only 5-10% of patients can maintain this discipline.
2.  It is expensive. Organic food is way more costly than processed food. Consider meat & fish, it’s 50% more expensive than the normal stuff. The same goes for organically grown foods.

Supplements? A minority of patients can benefit from zinc supplements, so if you want to give this a go, it is a sensible avenue. 

My final thoughts on treating acne? Approach this methodically if you are serious about your skin.