Treating Acne in Transgender Persons Receiving Testosterone

A Practical Guide

Rakan Radi; Sarah Gold; Juan P. Acosta; Jason Barron; Howa Yeung

Am J Clin Dermatol. 2022;23(2):219-229.

Abstract and Introduction

Abstract

Transgender persons who undergo masculinizing hormone therapy experience a wide array of dermatologic effects as they initiate and maintain testosterone therapy. Acne is one of the most common adverse effects for many transmasculine patients receiving testosterone. Acne can worsen body image and mental health, with significant impact on quality of life in transgender patients. Specific training and awareness are needed for a clinically and culturally competent encounter while providing care for the transgender patient. This article provides a practical guide for the treatment of testosterone-induced acne in transmasculine patients. Recommendations on creating a welcoming clinical setting, taking a gender-inclusive history, and conducting a patient-centered physical examination relevant to acne care are provided. Assessment of reproductive potential and the appropriate contraceptive methods before prescribing acne treatment with teratogenic potential in transmasculine patients are examined. Interactions between acne treatments with gender-affirming therapies are explored. For patients with severe or treatment-refractory acne, indications, contraindications, and barriers to isotretinoin prescription, such as the US iPLEDGE program, are examined. Multidisciplinary approaches to acne care, involving mental health, reproductive health, gender-affirming hormone therapy and surgeries, are adopted to guide isotretinoin treatment.

Introduction

Acne vulgaris is a common skin condition affecting 9.4% of the global population,^[1] representing the second highest cause of disability from skin diseases globally.^[2] Acne has multifactorial etiologies that include hormones, inflammation, stress, and medications.^[3,4] Hormonal acne is caused in part by sebum overproduction due to endogenous androgens such as dehydroepiandrosterone, dehydroepiandrosterone-sulfate, androstenedione, testosterone, and dihydrotestosterone.^[3] Estrogen, on the other hand, reduces sebum production.^[3] Hormonal acne tends to cluster in areas that exhibit higher dihydrotestosterone selectivity, such as the lower face, chin, and jawline.^[3,5] Hormonal acne can be more pronounced in patients receiving exogenous androgens, affecting the chest, upper arms, and back.^[6] Exogenous testosterone therapy is indicated for cisgender men for hypogonadism, cisgender women for hypoactive sexual desire disorder, and transgender persons as part of gender-affirming masculinizing hormone therapy.^[3,7–10] The aim of this article was to review the epidemiology and impact of acne, overall approach to acne care and terminologies, and management for mild to severe acne and specific considerations for isotretinoin.

Terminology and Definitions

Transgender persons are persons whose gender identity or expression diverges from their sex assigned at birth.^[11] The adjective 'trans' is also commonly used to refer to transgender among transgender community members. Gender identity is defined as the internal sense of being a man, a woman, or some other gender. For example, a transgender man is a person whose sex assigned at birth was female and identifies as a man. Since gender identity expands beyond binary constructs of male and female, the term 'transmasculine persons' is used inclusively to refer to transgender persons who were assigned female at birth who do not identify as women, such as transgender men and gender non-binary persons. Many transgender persons seek gender-affirming therapies aimed to alleviate gender dysphoria and to improve mental and overall well-being.^[12] These treatments may include gender-affirming hormone therapy, surgical procedures, social transitions in gender expression, and/or psychotherapy. This paper focuses on understanding and treating acne that develops in transmasculine patients who receive gender-affirming testosterone therapy (often known as 'T') to achieve masculinization as congruent with their gender identity.

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Table 1. Example language for history taking for acne encounters with transmasculine patients
Provider question checklist for transmasculine patients
Introduction
Tell the patient your name and pronouns
Name and pronouns
"How would you prefer to be addressed?"
"What are your pronouns?"
Sex and gender
"What sex were you assigned at birth?"
"How would you describe your gender identity?"
Hormone therapy and gender affirmation surgery
"Have you ever or are you currently taking hormones or any other medications related to gender?"
"Have you ever had or thought about having any gender-affirming surgeries (e.g., top or bottom surgeries)?"
If so, "then when?"
"Can you tell me what organs you have or what you have had removed as part of your transition?
"Do you still have a uterus/ovary? Are these words you are comfortable with?"
"Have you pursued any other changes in your appearance or body to bring it closer to your sense of self?"
Sexual history
"Are you currently sexually active?"
"By choice or circumstance?"
"What are the genders and bodies of your sexual partners?"
"How do you have sex with them?"
"What body parts do you use?"
"Do you have sex with men or people who produce sperm?"
Pregnancy
"Do you desire pregnancy now or in the future? Do you use anything for pregnancy prevention?"
"Do you use condoms for prevention of pregnancy and sexually transmitted infections? How often do you use condoms?"

Table 2. Specific considerations on acne prescriptions for transmasculine patients
Medication	Special considerations
Tazarotene	Teratogenic; advise patients of childbearing potential to consider contraception
Isotretinoin	Teratogenic; transmasculine patients of childbearing potential must use two forms of contraception Consider delayed wound healing effects in patients aiming to undergo gender-affirming surgical procedures Possible hepatotoxicity worsened with testosterone therapy Possible symptoms of depression
Doxycycline	Teratogenic; advise patients of childbearing potential to consider contraception
Trimethoprim-sulfamethoxazole	Potentially teratogenic; advise patients of childbearing potential to consider contraception
Spironolactone	Teratogenic; advise patients of childbearing potential to consider contraception; discuss possible feminizing effects
Clascoterone	Targets the action of testosterone in the skin; may be a good option to consider in transmasculine patients
Oral contraceptive pills	Discuss possible feminizing effects as they relate to transition goals

Table 3. Primary methods of contraception appropriate for iPLEDGE in transmasculine patients
Method of contraception^a	Efficacy	Spontaneous bleeding and spotting risk^b	Effect on menstrual bleeding^b	Effect on cramping^b	Chest tenderness	Duration/dosage
Hormonal implant	> 99%	High	Reduced/stopped	Decreased	May be reported	3 years
Hormonal IUD	> 99%	High	Reduced/stopped	Variable	May be reported	5 years
Copper IUD	> 99%	Low	Increased bleeding	Increased	None	10 years
Tubal sterilization	> 99%	None	None	None	None	Permanent
Hormonal injection	> 97%	High	Reduced/stopped	Decreased	Occasional	3 months
Vaginal ring	> 92%	Low	Reduced/stopped	Decreased	During the initial stages	Monthly
Hormonal patch	> 92%	Low	Reduced/stopped	Decreased	During the initial stages	Weekly
Combined oral contraceptives	> 92%	Low	Reduced/stopped	Decreased	May be reported	Daily

IUD intrauterine device
^aContraceptives containing female sex hormones may not be acceptable to some transmasculine patients due to their connection with a discordant gender and potential concerns for feminizing effects
^bAmenorrhea may be a desirable effect for some transmasculine patients who continue to have bleeding while taking testosterone, while spotting, increased bleeding and cramping may be undesirable effects and may trigger gender dysphoria