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The great clear skin wealth divide – why treating acne is a privilege

For those with severe breakouts, it’s the difference between waiting years for free treatment or paying £2,000 to jump the queue

If there’s anyone who knows the bumpy road that is acne treatment, it’s Lou Northcote. The 23-year-old model and activist behind #freethepimple has had her pick of top dermatologists to ask expert advice of, and via her Instagram account – where thousands praise her for unfiltered selfies – she receives no shortage of well-meaning suggestions for achieving clear skin.

Yet, she’ll tell you calming breakouts is not that simple – just like many other sufferers, a group comprising not just teens, but also people like 27-year-old me (an estimated half of 20- and 30-somethings have the skin condition, caused when hair follicles become blocked). Her “crazy rollercoaster” to find a solution began, aged 16, with dabbing on prescribed creams. It graduated into years popping six-month courses of antibiotics, that did little to soothe cysts so sore she had to take painkillers, before finally culminating in a referral to see an NHS dermatologist for medication that would have cost £2,000 had she gone private. 

That’s because acne treatment in the UK is arguably a game of privilege. Accessing the right expertise requires either a generous bank balance or the luxury of patience. We’re lucky enough to have a national health service that allows you to see a skin doctor, called a dermatologist, for free, but it can often take years to secure appointments, which in the meantime can chip away at sufferers’ mental wellbeing. Speed up the process by going private, however, and the prospect of £400-an-hour sessions would make most wince. I fall in the gap, like most people – my acne isn’t bad enough for a coveted referral, but shelling out on my skin simply isn’t an option when there’s rent to pay.

Most people start on a level playing field, according to Dr Daniel Glass, a consultant dermatologist who treats NHS patients as well as those at his The Dermatology Clinic on London’s prestigious Harley Street. We see our GP who will usually prescribe a topical treatment – such as an over-the-counter cream like benzoyl peroxide or a retinoid. If that doesn’t work, they may add several long-term courses of antibiotics. For women, hormonal options, such as the pill, will be floated. Don’t be surprised when this process takes a while. “Acne is a long-term condition, and you need to give time for each option to be tried out to see if it responds – which can take many months,” Glass explains. Most mild cases are successfully cleared up during this period.

Often, only once all these solutions have been ruled out, will a GP consider referring you to a skin specialist – and the threshold can vary greatly. “The criteria can include having severe acne, cystic acne, moderate acne that’s not responded to treatment, or acne that’s beginning to scar,” says Dr Glass. “Some may base referral on psychological symptoms as well. Patients may have objectively mild acne, but their confidence and mental wellbeing is so impacted that they find it difficult to even leave the house.” You can, of course, accelerate this process by booking in to see a dermatologist privately. But doing so won’t come cheap – fees can vary hugely, but a quick Google will point you in the direction of one, albeit very experienced, London-based skin specialist charging £450 per appointment. 

It was an option Laura – a 28-year-old PR and social media executive based in Wiltshire – considered, until she realised that dermatologists in her area still wanted her to have received a referral. After her first teenage flare-up, doctors repeatedly insisted her acne wasn’t that bad – and prescribed her topical treatments, antibiotics, and the pill. “At one point I was told ‘I’ve seen skin much worse than yours, so there’s no need to worry’,” she recalls. “But I was struggling – not going outside without make-up and suffering bouts of anxiety.” It got to the point where Laura arrived at a facial only to be told by the therapist they couldn’t do anything because her skin was so aggravated. “I pleaded with my doctor to refer me,” she says. “As soon as I started getting upset, that’s when they did.” 11 years after she first sought help.

“At one point I was told ‘I’ve seen skin much worse than yours, so there’s no need to worry’ but I was struggling – not going outside without make-up and suffering bouts of anxiety. I pleaded with my doctor to refer me” – Laura 

The differences in acne treatment depending on your income continue to widen after referral and the time it takes to make it into a dermatologist’s office can be a postcode lottery. Lou had to wait seven months to be seen by a dermatologist. Laura is eight months and counting. “The biggest benefit for those who are able to afford to go private is the speed at which a dermatologist can be accessed; waiting times on the NHS for acne can be many months as they fall into the the ‘routine’ rather than ‘urgent’ category,” explains Dr Anjali Mahto, consultant dermatologist and author of The Skincare Bible, who herself experienced cystic acne from the age of 12.

This issue of inequality runs further than skin deep. Research estimates that 10 million people in the UK with a skin condition suffer from poor mental health, and they are also 63 per cent more likely to experience depression. All at a time, let’s not forget, when social media-ready perfect skin is the holy grail. “Delay can not only potentially mean a higher risk of the acne becoming more severe, development of scarring, but also mental health issues such low self-esteem and poor body image,” notes Dr Mahto.

Then there’s the type of treatment which may be offered. “In the private sector, treatments such as chemical peels, laser, and light may be offered,” says Dr Mahto. Additionally, one of the reasons acne sufferers desire an NHS referral is to secure free access to a medication called roaccutane (the brand name for isotretinoin). It’s controversial – due to its hotly-debated suicide links, and scary-sounding side effects, like possible blindness, hair loss, and joint pain – but it’s one of the most effective ways to decrease the level of oily breakout-causing sebum. There’s rigorous monitoring involved during the eight-month course, including regular blood and pregnancy tests. Lou is prepared to travel an hour on a bus to a London hospital for hers. Going private would have cost her around the £2,000 mark.

The NHS also, unlike private clinics, won’t fund treatment for acne scarring. “It’s perceived to be more cosmetic, and the health service has a budget – you’ve got to stop somewhere,” explains Dr Glass. The issue of money is a sore one. “The difficulty we have is that it’s a common medical problem, and if every patient was sent to a dermatologist, current services would be unable to cope,” says Dr Mahto. The fact that “non-emergency” dermatology is often side-lined can be incredibly frustrating to those who aren’t able to afford to go private. “You really have to jump through so many hoops to be given any treatment or to see a specific skin doctor through the NHS,” says Lou. “But this is the craziness of skin, at the end of the day my acne isn’t life-threatening and while it may cause me pain, it is somewhat vanity.” However, she acknowledges that this becomes more complicated still when you consider mental wellbeing, the reason why she began opening up about her skin on social media in the first place.

However, for those whom no professional help from conventional medicine is quickly (or will ever be) forthcoming, the internet is a tempting pool of alternative solutions. But it’s also an unregulated wild west. “When I was younger I would Google acne remedies every day and I have tried the most random stuff,” admits Lou. “I’ve even put turmeric on my face because someone said it would help, and I dyed it yellow.” She also paid to see a nutritionist who identified dairy and gluten intolerances, likely triggered by long-term antibiotics she had been prescribed without anyone telling her of the need for probiotics. “They helped me repair my gut – I can now eat gluten again without getting bloated,” she reveals. “Which is great for my body, but my skin is still not clear.”

Laura agrees: “The reason I wanted to see a dermatologist was to get proper advice. I don’t mind investing in my skin; I’ve tried so many acids, cleansing products, nutritional supplements, and other alternative solutions – but it’s hard to know who to listen to online.” She’s also been on a course of laser and peels, but the woman she saw was not a dermatologist, and she’s since learned that you should wait until acne is inactive or you could make it worse. “I’m getting so much information from websites and ‘experts’, and consequently doing so many things to my skin, that I’m actually damaging it,” she notes. 

Misinformation and bogus miracle cures aside, trying out different products can add up. I’ve spent hundreds over the years, while Laura estimates her expenditure runs into the thousands. Lou believes acne sufferers are easy targets for blemish-fighting claims from an industry – projected to be worth £6bn globally by 2025 – that’s trying to cash in. “When I was younger, all you would see is adverts using a model with clear skin,” she notes. “On social media now there are lots of before and after images used to show that spots have ‘magically’ gone away in a week, and not all of them are genuine. There’s no ruling behind that.”

Is skincare even the answer? Salicylic acid, niacinamide, and glycolic acids are just some of the hero ingredients hailed online as helping breakouts. “It’s important to realise these aren't cures for acne,” Dr Mahto explains. “They are legally in the category of cosmetic products and not drugs – and in breach of the Advertising Standards Authority if they claim to be medical treatments. Good skincare is an adjunct to managing the condition, but many of the common ingredients used are in low concentration, so will not be as effective as prescribed options.” In short: We need to re-frame acne as a medical problem, not a cosmetic or beauty one which can be fixed with the right cleanser or moisturiser. 

The same goes for blue light therapy, which turned up last year promising salon-level acne treatment for a mass market. For instance, you can buy a Neutrogena ‘pen’ featuring the technology for a very affordable £30. “There is some data suggesting that blue light is anti-inflammatory for mild acne, but at-home devices are often expensive and there is no guarantee they will work,” warns Dr Mahto. “Where possible, it’s better to have a proper assessment of your skin and receive expert advice rather than over time spending hundreds of pounds on products and devices.”

So, it’s always best to ask a pro. Where to look for more affordable options? Cutting edge London-based skincare clinic Young LDN – that specialise in acne treatment – offers free initial consultations. “We will always be aware of someone’s budget,” says founder Sue Carroll. They offer deep cleansing, extractions, dermaplaning, LED light therapy, enzymes, and chemical peels at 15 per cent off to those under 23. There’s also sk:n clinics that has 52 branches around the UK, with dermatologist appointments starting at £100, and 0 per cent finance available. 

One of the new-age acne treatment services I’m particularly impressed by is Dermatica. Their team of dermatologists give tailored advice and are the only company in Europe to offer personalised prescription treatments online – all at a very affordable £19 per month. “Unlike cosmetic products which often have no evidence or efficacy all the ingredients used in our treatments are the same ones you would get if you went to go see a dermatologist,” it explains. After filling in a very detailed questionnaire and sending off pictures of my face from multiple angles, I’m told a concoction of adapalene, niacinamide and clindamycin is on its way to me in the post. Sure, an in-person appointment and salon-based treatments will always be the gold-standard, but for those who need a less pricey, quality alternative, I think it’s pretty spot on.