Finding Acne Experts

Acne can be tough to treat, especially on your own. If you’re ready to consider a visit to the doctor, you’ve come to the right place. Here, I look over the landscape of professional help that is available to manage your acne. Some general healthcare providers learn about treating acne as a part of their medical training, and your healthcare provider may be one of them.

I fill you in on how to determine whether that’s the case. If it’s not, no problem: I explain how to find a dermatologist, a specialist who deals with all skin disorders. I also give you some pointers about how to make the most of your experience in managing your acne with the experts.

I give you the “ins and outs” of dealing with the first appointment, the paperwork, insurance issues, prescription refills, and all that other annoying, but necessary, stuff. And I tell you what to expect from your treatment and how to have a good working relationship with your acne doctor.

Establishing Basic Goals of Treatment

Whether you visit your primary care provider or a dermatologist, the basic aims in treating your acne are usually the following:

  • To prevent your acne from scarring or to prevent further scarring if it has already been present.
  • To decrease the physical and emotional pain of having acne lesions.
  • Of course, to make you look better!

Discuss your goals with your healthcare provider. Get a feel for what to expect from your treatment, how long it will take, and what to do if it doesn’t work out so well. In other words, try to get an idea about a best-case/worst-case scenario. Seeing a dermatologist or other skin-care specialist can be part of that plan.

Seeing Your Primary Healthcare Provider

Visiting your primary care provider (PCP) is a logical first step because, nowadays, more and more healthcare providers are learning about the treatment of diseases of the skin, including acne. They have more tools at their disposal to treat your acne than you do because they’re often able to write prescriptions, if necessary, for medications.

Plus, even if they aren’t able to help you manage your acne, many insurance policies require that your PCP provide a referral for specialists, including dermatologists.

Working together to treat your acne

Your PCP may be a(n):

  • Pediatrician: A physician who specializes in children.
  • Family practitioner: A generalist who treats routine medical problems for people of all ages.
  • Internist: A physician who specializes in treating medical conditions of adults.

Your PCP may also be a healthcare specialist who isn’t a doctor:

  • Physician assistant (PA): Physician assistants work under the supervision of a physician. They work interdependently with the understanding that the physician is available for consultation whenever needed. PAs can treat patients and, in most states, prescribe medicine.
  • Nurse practitioner (NP): A nurse practitioner is a nurse with a graduate degree in advanced practice nursing. Some NPs work without physician supervision, and others work together with physicians as a joint healthcare team. Their range of practice and authority depends on state laws. For example, some states allow nurse practitioners to write prescriptions, and other states don’t.

Some PAs and NPs are specifically trained in dermatology, and some even specialize in areas such as acne. In fact, some PAs and NPs may actually have more training in dermatology than pediatricians, internists, and family practitioners.

An advantage to seeing a physician assistant or nurse practitioner is that it may also decrease the waiting time necessary for an appointment with a busy physician. But the next question is whether or not your PCP is able to manage your acne.

You should always find out about the experience your PCP has had in treating acne. The best way to find out is by simply asking him. If you and your primary care provider decide to tackle your acne together, she’ll likely give you one or two topical medications to apply to your skin.

She may also give you certain oral antibiotics that are effective in treating acne. Be patient and give the medications a chance to work. Topical medications can take weeks to months to show what they can do. Keep in mind that medications should be used as directed or they can’t work nearly as well.

Make a habit of taking or applying your acne medicines like you make a habit of brushing your teeth. It’s not unusual for acne to last for many years, so ongoing treatment may be necessary. It may come to pass that despite the best efforts of your PCP, your expectations for improvement in your acne haven’t been met.

You’ve been through the usual stuff — pills, creams, and lotions that have been prescribed for you and you’re not getting any better, or not better enough to suit you.

In this case, seeing a dermatologist, the expert in the management of this difficult and pesky disorder, is an option to consider. Just about every case of acne can be cleared up, but sometimes it takes a dermatologist’s help.

Requesting a referral to see a specialist

If your health plan requires that referrals to specialists be authorized or approved by your PCP, who is often your best source, then you need to ask for the referral.

However, if your health plan allows you to make appointments without a referral from your PCP, your PCP is still an excellent source for helping you to identify a qualified professional in your community.

You can enter into a specialist’s care via a referral in a number of different ways, but in most cases, your specialized care typically falls into two categories:

  • For a consultation: In some cases, your PCP may prefer to have you obtain a dermatology consultation, which means that the specialist will evaluate you and make recommendations for further care, and then send you back to your PCP for continuing treatment. For more on what to expect from a consultation, see the sidebar “What is a consultation?”
  • For ongoing treatment: In this situation, your PCP requests that your acne-related care remain in the hands of the specialist. You would still continue to see your PCP for routine things like illnesses and injuries, but your specialist will handle all things related to your acne.

In either case, the medical records of your care to date should be sent or brought by you to the dermatology specialist to review so that any relevant medical information such as past medications and therapies will be available to her.

Finding the Right Dermatologist for You

All dermatologists aren’t created equal. Some are very talented and up-to-the-minute on the latest knowledge for treating your acne, while others may lag in their capabilities. Start by asking your regular PCP for the person who might best treat your acne.

You may want to ask him whom he would send a member of his own family to if they had acne. A dermatologist must have a degree in medicine, either as a Medical Doctor (MD) or a Doctor of Osteopathic Medicine (DO). Dermatologists first go to medical school and then to a residency program for their specialized training.

They’re experts in the diagnosis and treatment of diseases of the skin (including hair and nails) in both pediatric and adult patients. Depending on the doctor’s specialty and interest, a dermatologist may also receive very specialized training in one or more of the following procedures:

  • The use of lasers and other special light delivery systems to help treat acne
  • Various cosmetic techniques such as Botox and “filler” injections to improve the appearance of the face
  • Surgical corrective resurfacing procedures to reduce acne scars

In the following two sections, I tell you how to go about seeing a dermatologist, a PA, or an NP and what to do when you get there. From here on out, I refer to all of those professionals as dermatologists.

After you put together a list of prospective dermatologists, call each office and ask if the doctor accepts your health insurance plan. If the doctor isn’t covered by your plan, ask yourself if you’re prepared to pay any extra costs.

Using networking techniques

In addition to checking in with your PCP, you could also locate a specialist on your own by asking your friends, family, or other members of your community who have been satisfactorily treated by a particular dermatologist. Don’t be shy. If you know someone who had acne and now shows improvement, ask her how she did it.

She’ll likely be thrilled you noticed and happy to share the info. If your house needed a renovation, you’d likely ask for references about any contractor that you might consider. The same holds true for anyone who is going to be responsible for your skin, the “house” you live in.

Checking in with professional associations

The American Academy of Dermatology is the largest dermatologic association in the United States. Their Web site can help you locate a dermatologist in your area.

This site can also provide biographical information about many academy member dermatologists, including their education, specialized training, office hours, and whether they accept your health insurance plan. You can also find detailed maps showing how to get to their offices.

You can also call or write to the American Academy of Dermatology, 930 E. Woodfield Road, Schaumburg, Illinois, 60173-4927; 847-330-0230. You can find out whether the doctor you’re interested in is board certified in dermatology.

“Certified” means that she has completed a training program in the specialty of dermatology and has passed an exam, or “board,” that assesses her knowledge, skills, and experience to provide quality patient care in that specialty.

That means that all the training and tests have been met by the doctor and approved by the American Academy of Dermatology. I would certainly recommend that you look for a dermatologist who is board certified.

Many dermatologists have teaching positions at academic centers such as major hospitals and medical or osteopathy schools. You can check out their credentials and academic positions online or by asking your local public or university reference librarian to help you.

Looking at your insurance directory

You know that list of names that came in the mail or that were given to you when you signed up with your HMO or other health insurance company? It contains a list of specialists who are in their network of providers, which means the doctor has been approved by your HMO or insurance company.

An advantage to using an innetwork specialist is that most insurers check out the providers on that list and hold them to high standards. Moreover, if you go to a specialist who is on this approved list of providers, most of the medical bill will be covered by your insurer.

Who doesn’t want that? If someone you wish to see isn’t on that recommended list, it doesn’t always mean that the specialist isn’t up to snuff. In fact, it may be worth your while to go out of network to find the right person for you; however, it will likely cost you more money to do so.

Check with your insurance company to see whether they have an online directory. Typically, the directory doesn’t include recommendations, per se.

But you can search their directory based on specific criteria, like distance from a location (like your home or child’s school) or office hours. Often you can click to find a map directly to the dermatologist’s office and get the phone number to make an appointment right away.

Perusing the phone book and advertisements

Believe it or not, the phone book can help you with your choice. Specifically, it can help you choose:

  • A dermatologist that’s close to your home or your child’s school. That makes sense.
  • A male or female. You can then decide who you or your child would be most comfortable with.
  • One that may speak your language or has translation available to you if you don’t speak English. You could call to find out.

But remember, the bigger ad isn’t always better. Unfortunately, the late 1970s and early 1980s saw the removal of legal restrictions against advertising by those in the legal and medical professions. I advise you to distrust a doctor who advertises via large billboards, television, newspapers, gigantic yellow page ads, or subways.

Some of these doctors may start treating their patients as customers, rather than as patients. I also strongly advise you to avoid skin-care spas that advertise laundry lists of treatments that they offer.

I’ve seen an add that lists “laser treatment for acne scars, male breast reduction, breast enlargement for women, leg vein removal, buttock enlargement, buttock reduction, cosmetic skin surgery, broken blood vessels, microderm-abrasion, chemical peels, laser lunchtime super peels, collagen/Botox treatments, hair restoration, laser hair removal, body contouring, liposuction.”

And last but not least, in smaller print, “acne, eczema, skin cancer screening, warts, mole removal, and rashes.” And maybe they can check your car’s tire pressure and oil while you’re there.

Going to the Dermatologist for the First Visit

Whether the person you’re seeing is a dermatologist, a physician assistant, or a nurse practitioner, it’s a good idea to come prepared for your first visit.

Taking stock of your medical history

Before you walk out the door for your first appointment, review your medical history. Be prepared to tell the dermatologist what medications you take and what medical problems you have that, unknown to you, might play a role in your having acne or the treatment your doctor recommends.

Here are a few things your dermatologist may want to know:

  • Allergies: Do you have any allergies to medications?
  • Other skin conditions: Do you have a history of eczema (an itchy, inflammatory skin problem that’s often hereditary and makes your skin very sensitive) or contact dermatitis (an allergic reaction or an irritant response to things that have touched your skin)? These problems can be important because they can make your skin more vulnerable to some of the topical treatments that are used to treat acne.
  • Medications, vitamins, and supplements: Go through the items in your medicine cabinet. If you’ve recently swallowed it or rubbed it on, your doctor needs to know about it. Bring the medications you’ve been using to treat your acne into the examining room.

The actual tubes and bottles can help your dermatologist read all the ingredients (both active and inactive) in the medications and make more informed recommendations about where to go from here. If you don’t have the empty tubes or bottles with you, write down the names of the medications and their dosages.

If you’ve been using a medication, describe how long you have used it. Note any subjective information like: Was it irritating? Was it helpful? Also make a list of non-acne products, such as birth control pills, vitamins, herbs, supplements, or other medication. Include the medications’ names and dosages.

Preparing on the day of your visit

With your medical history in hand, there are a few additional steps you can take to make the most out of your first office visit:

  • Arrive 15 minutes early: On your first visit to any healthcare provider’s office, you’re generally expected to fill out a form or two. Your new doctor will need — at a minimum — your name, address, medical history, drug allergies, and current medication.

You will also need to provide information about your insurance coverage and how you expect to pay for your visits (such as with cash or credit card). Arrive at the office earlier than your scheduled appointment to take care of these issues.

  • Bring a parent: If you’re a minor, you should come in with a parent or guardian. A minor is a person under the legal age of consent, which is generally 18. Certain procedures or medications will require parental consent, so be sure, especially on that first visit, that an adult or legal guardian is present.
  • Bring your insurance card: You will be asked for your insurance card or the card of the policy holder if coverage isn’t in your name. If you don’t have a card with you, you should at least know the name and date of birth of the cardholder.
  • Remove your makeup: When you see a dermatologist and expect a careful examination of your face, you shouldn’t be wearing makeup to conceal the reason you went there in the first place — your face!

I know from firsthand experience that trying to see through makeup is like trying to look out of a window when it’s fogged up. The time involved in removing makeup in the examining room is better spent talking about your skin.

So remove it before entering the examining room. If you hate appearing in public with a “naked” face, you can always reapply your makeup before you leave the office.

Meeting the doc

Your first visit with your doctor will involve a review of your medical history, focusing on the acne angle, an examination of your skin, and treatment recommendations.

In addition to checking out your face, he may want to look at your chest and back because acne often occurs there as well. If your acne only involves your face, then there’s no need for you to undress.

Communicating your personal acne story

The following are my typical first-visit questions about acne. You will undoubtedly be asked some or all of them. To ensure that you don’t forget anything and that you and your doctor can make the best use of your time together, you may want to spend a few minutes thinking about these questions before the visit:

  • How long have you had acne?
  • Does it run in your family?
  • Is there anyone in the family with severe scarring acne?
  • What do you do to your skin each day — such as how many times a day do you wash your face?
  • Are you applying or taking any medications?
  • Do you pick at lesions?
  • What seems to make it worse? Diet, exercise, medications, stress?
  • What has been helpful? Sunlight, vacations, medications, winning the lottery?

And if you’re a female, you’ll also get these old standbys:

  • Does it get worse before your period or at midcycle?
  • Does makeup make it worse?
  • Are your periods normal?
  • Are you taking birth control pills and do they seem to help or worsen your acne?
  • Have you noticed any unusual or excessive hair growth?

Understanding treatment recommendations

Based on a physical exam and your discussions with your dermatologist, she will recommend treatment options, which will likely include some sort of medication. Before leaving the examining room, make sure that all your questions have been answered.

Your doctor is there to help you through the process, and questions are always welcome. You should know what to expect from your treatment and get a clear sense of its goals. For example, make sure that your doctor has answered these questions, and if not, ask them:

  • What are the side effects of the medication you are prescribing?
  • How long will it take for the treatment to work?
  • How long do you think my acne will last?

But my standard reply when a patient asks, “How long will it take for my face to clear up?” or “How long will I have acne?” is something like “Gee, my crystal ball is in the repair shop this week!”

Good Working Relationship

As in any ongoing relationship, especially if it may last for a long time, it’s important to feel comfortable and have a sense of genuine rapport with your dermatologist. Key points in building this relationship include closely following your doctor’s instructions, being patient, and feeling free to ask any questions that you may have.

Following instructions

You need to know some very specific information before you start popping those pills or rubbing the acne stuff on your face and body. And just like that manual that came with your new iPod or computer, the medication your doctor prescribed comes with instructions.

If you’re like me, you’ll probably find them much easier to understand than your iPod or computer instructions. Read those instructions! Both the instructions that come with each medication and any handouts given to you by your doctor or anyone on her staff contain valuable information about your treatment regimen.

If you weren’t given an instruction sheet or other handwritten directions regarding medications, call your doctor for any necessary clarification.

Being a “patient” patient

Some folks expect things to work overnight and don’t give the medications a chance. Impatient patients are a very common problem! If you think the stuff your doctor gave you isn’t working, often it’s because you haven’t given it enough time to really kick in.

For example, benzoyl peroxide may take four to six weeks to really start working, and some topical medications such as the retinoids can take up to three months before they show their stuff. You see your face in the mirror every day. Your dermatologist only sees it when you come to the office for your appointments.

The improvement, or lack thereof, will be much more evident to him. Sure, you’ll have some good days and bad days, but overall, it’s important to stick with the routine and give it a real chance to work and judge the progress on a monthly rather than a daily basis. Rome wasn’t built in a day and your acne won’t disappear in a week!

Telephoning the dermatologist with questions

You, your healthcare provider, and her staff should view your acne treatment as a team effort. Like any good team, communication here is important, so don’t hesitate to call the doctor’s office with questions or concerns you have outside of your normal office visits.

Although office policies vary, the best time to call is in the morning after 9 a.m. when most offices are open. Many offices go “on service” during lunch hours and an answering machine (voicemail purgatory) or operator who isn’t in the office may answer your call.

If you need to cancel or change an appointment, the receptionist can handle that information while you’re on the phone. Other procedural-type queries may be fielded by members of the dermatologist’s staff. And, if you have a fairly straightforward medical question, the receptionist may have a nurse call you back.

But for more complicated situations and real “trouble shooting,” ask to speak to the dermatologist or have him call you back directly. Simply tell the person who answers, “I would like to speak to the doctor, and it’s very important. Please have him call me back.”

Leave the times and phone numbers where you can be reached in the next 24 hours. (If it’s not an emergency, don’t say it is one!) The staff will then pull your chart and leave it for the doctor to review.

Here are some of the most common scenarios that call for a quick call to your dermatologist instead of sitting back and waiting for your next appointment, which may be three months away:

  • Your medication isn’t working. If a medication is causing you problems, not working, or for some reason you can’t or won’t use it, call the dermatologist about it — or if you’re a kid ask your parent to call. Don’t wait.
  • You forgot to ask certain questions during your appointment. Call the dermatologist rather than waiting until your next appointment.
  • You need refills or you lost a prescription or medication. Possibly you lost the actual prescription or you left the medication at your grandparents’ house, at a camping trip site, or your dog ate it. Often the receptionist or nurse can take care of refills over the telephone. (If your dog ate your prescription, you may also need to call or visit the vet!)

More often that not, when you call to ask for a refill, you’ll find that there is a specific policy that is carefully followed. Most dermatologists, as well as many other healthcare providers, are more liberal when it comes to refilling topical medications.

However, oral drugs carry greater risks and the policy regarding refilling them will necessarily be much stricter. Many dermatologists insist that you be seen in their office if more than a year has elapsed since your last office appointment before mailing you or telephoning your pharmacy for a refill.

This is especially the case when the dermatologist isn’t very familiar with your case and perhaps has only seen you on one or two occasions.

  • You need a different prescription. Maybe you can’t afford the prescription and need a generic substitute.
  • You lost information about the medication. Maybe you forgot how often to take the pills or your PCP wants to give you a medicine for another condition and you want to know if that drug can be taken along with your acne medication.
  • You’re concerned about side effects. Maybe the stuff the dermatologist gave you smelled horrible, made your dog sick, upset your stomach, gave you a yeast infection, bleached your nice blouse, irritated your skin, or made you itch like crazy!
  • You need a referral. For instance, you’re moving to Albuquerque and you want the name of a dermatologist in that city.

Deciding to change dermatologists

You can switch dermatologists if you don’t have a good communication with the dermatologist you’re seeing or if you’re not satisfied with the progress of your treatment.

You or your parent might speak to the dermatologist about these issues and maybe give her and the medication(s) more time or another office visit or two before deciding to change doctors.

If you’re still dissatisfied, ask your PCP for another referral, or repeat the measures that I talk about in the earlier section, “Finding the Right Dermatologist for You.”