The Hard Truth About Online Skincare Prescription Services

Whether you're happy with your skin or you'd like a little help, you've no doubt spotted at least one recent ad, TikTok or Instagram story singing the praises of online dermatologist services. Thanks to the pandemic, skincare has gone digital, with websites and apps promising to diagnose your skin gripes and offer up prescription-strength skincare to treat issues like acne, rosacea, pigmentation and more.

It goes like this: share your skin concern, answer a handful of questions about your skin's history, upload a couple of selfies and a dermatologist will get in touch with a skincare treatment plan, which is then delivered straight to your door. Influencers, TikTokers and beauty enthusiasts will be quick to tell you that their skin has been transformed by the help of online services like these — popular ones being Dermatica and Skin + Me — and the reviews are certainly impressive.

The rise in digital skincare services makes total sense. L'Oréal's "Life After Lockdown: The Skincare Trends Report" declared that the online conversation around skin concerns has risen by 71% since pre-lockdown. It's true — we're dealing with the aftermath of maskne (acne caused by wearing face masks), not to mention the effects of stress and anxiety as we begin to re-enter the real world. Online prescription skincare is both affordable (plenty of services are under £20, while a physical dermatologist appointment will set you back into the hundreds) and easy to access in the comfort of your own home.

Consultant dermatologist Dr Anjali Mahto isn't surprised that people are going online to look for solutions for managing their skin. "There is a huge shortage of dermatologists in the UK," says Dr Mahto. "Access to us has always been difficult but even more so after COVID, because the waiting lists are so long." Not everybody can see a dermatologist and referrals from GPs are known to take a while. Dr Mahto says that over-the-counter skincare or online subscriptions and services are like a halfway house, and help to make prescription skincare accessible to everyone. "If you can't get an NHS appointment and you can't afford a private dermatologist, at least it offers an in-between solution." Dr Derrick Phillips, consultant dermatologist and British Skin Foundation spokesperson, agrees. "There certainly is a role for online dermatology consultations," he tells R29. "People are able to access expertise when they need it without being limited by geography and with minimal disruption to the working day." As a beauty editor with persistent hormonal acne and a penchant for skincare, I have tried — and loved — online skincare prescription services. But for the many positives, there could be some downsides, too.

Dr Mahto says that while plenty of online services have qualified dermatologists working for them, she has seen a handful of patients in her clinic who have fallen victim to misdiagnosis. "I see a load of people who assume they have acne and are told it is acne when it's not — it is rosacea, for example." Dr Mahto says this is an easy mistake to make when analysing pictures rather than looking at skin up close. "The bumps of rosacea can look similar to the bumps of acne," she continues. Thanks to misdiagnoses, some people are given the wrong skincare — with unwanted side effects. "In this scenario, I've seen people being prescribed high-percentage tretinoin (a high-strength retinoid) mixed with niacinamide as well as azelaic acid or an antibiotic. What this is doing is creating a lot more irritation and sensitivity, so it's triggering rosacea or perioral dermatitis," which is an inflammatory rash around the mouth. "I wouldn't necessarily want to be using active ingredients like these on rosacea-prone skin," says Dr Mahto.

It's worth pointing out that many dermatologists don't think prescription skincare services are inherently bad — it's safe to say they've changed the skincare game. But there are a few concerns. Dr Mahto explains that the wrong diagnosis can end up delaying treatment, which could cause long-term issues. "Twenty percent of people that have acne, for instance, will develop scarring," she says. "If you're not treating the acne quickly enough, the inflammation from the acne is going to result in damage to the skin." Another issue is that there is no account taken of the relationship between skin and mental health — something a lot of real-life consultations would include. "People can be really down about their skin but no one's really asking them that," says Dr Mahto. "Individuals are buying and using these treatments, and it's delaying what they actually need. That's not going to make you feel worse, of course, but your skin isn't going to get any better, either."

Dr Mahto says that she has seen people being prescribed skincare that quite clearly isn't going to work. It's not unusual for her to talk to patients who have used something for a long period of time and not noticed any real difference in their skin. "Because topical skincare products are easy to prescribe, people are given things like tretinoin," says Dr Mahto. "But if they have cystic acne, for instance, what they actually need is an oral medication."

Not long ago, Refinery29 health and living writer Sadhbh used an online prescription service to help with her acne. She was given tretinoin alongside antibiotics. Despite rigorously following the steps for over a couple of months, she didn't notice a positive difference. "My skin purged [resulting in more spots] and the antibiotics gave me gut problems," said Sadhbh, who had to take probiotics to mitigate the uncomfortable side effects. "I understand the impulse to democratise dermatology in this way but looking back on it now, there's no way it would work for every person because the reasons for their skin complaints are so complex," she says. "I have polycystic ovary syndrome (PCOS) and OCD, so my acne is both hormonal and exacerbated by obsessive picking. Antibiotics were never going to work for me – and hadn't in the past – but I don't think AI can calibrate what that would mean for skincare, unless the form was overwhelmingly thorough." Dr Mahto reports that she has seen patients being prescribed quite low skincare concentrations through online dermatologist services. Freelance beauty journalist Amanda* had a similar disappointing experience when she was prescribed tretinoin to treat her fine lines and wrinkles. "Even after using the product consistently for three months, I didn't notice a difference," she said. "I wouldn't use the service again."

Though plenty of online skincare prescription websites claim to provide personalised help, Dr Mahto believes in-person conversations are much more fruitful, particularly where ethics and certain ingredients are concerned. Take hydroquinone, for example, often prescribed to treat hyperpigmentation. The ingredient can be found in skin lightening creams in high concentrations and mixed with harmful substances like mercury, which means some are concerned about using it. "There is a lot of awareness now of hydroquinone in Black and Asian communities, and a lot of people don't want to use it as they don't want to be seen to be bleaching their skin," says Dr Mahto. But there is a difference between bleaching your skin and treating a localised area, she continues. "I had a patient recently who didn't want to use a hydroquinone product because of all the negative connotations. With this particular patient, I spent about 30 minutes explaining that there is a big difference in using hydroquinone in a low concentration in a controlled manner for an area of hyperpigmentation, versus skin lightening, where it might be used in an uncontrolled location and you don't know what it has been mixed with." Online, it's not as easy to have a detailed and open conversation with the dermatologist prescribing you the skincare, as Dr Mahto explains. "There are ethics that go along with the conversation. Unless you sit and you have that chat with somebody, it's difficult."

In an ideal world, anyone with a skin issue would have easy access to a dermatologist but as that's not the case, Dr Mahto can see why lots of us take help where we can. It's important to be savvy about the person giving you the information, though. The experts on board online prescription skincare services are often listed on these websites alongside their credentials. Dr Mahto recommends keeping in mind the following questions: "Are they qualified? What is their credibility? And are they trying to sell me something?" Dr Phillips concurs. "Consultant dermatologist and cosmetic dermatologist sound very similar, however, the former is a medical doctor who has completed an accredited UK dermatology training programme and is recognised on the General Medical Council (GMC) specialist register." The latter is a title that can be used by any doctor with little or no dermatology experience, says Dr Phillips. "To reduce the risk of incorrect diagnoses, incorrect treatments and the risks associated with both (like scarring, side effects, progression of the condition, impact on mental health), check that your doctor is on the GMC specialist register for dermatology and read their patient reviews."

If you've tried online dermatologist services and haven't seen much of a difference, booking an in-person appointment might be your best bet. If your budget won't stretch to this, here are a handful of useful tips for talking to your GP about skin issues and getting the right help once and for all.