Investigators Detail Approaches to Acne Care for Transmasculine Patients

Howa Yeung, MD, MSc

A new review from Georgia offered multidisciplinary approaches to acne care for transmasculine patients who receive gender-affirming testosterone therapy to achieve masculinization congruent with their gender identity.

Investigators noted that acne vulgaris, which affects 9.4% of the global population, has multifactorial etiologies including hormones, inflammation, stress, and medications.

Hormonal acne specifically is partially caused by sebum overproduction due to endogenous androgens including dehydroepiandrosterone, dehydroepiandrosterone-sulfate, androstenedione, testosterone, and dihydrotestosterone, while estrogen reduces sebum production.

Hormonal acne can be more pronounced in patients receiving exogenous androgens, a therapy often indicated for cisgender men for hypogonadism, cisgender women for hypoactive sexual desire disorder, and transgender persons.

As such, investigators led by Howa Yeung, MD, MsC, Department of Dermatology at Emory University School of Medicine, Atlanta, Georgia, reviewed the epidemiology and impact of acne care in transgender persons.

Acne Prevalence in Transgender Persons

Hormonal acne in transmasculine persons receiving testosterone tends to manifest in similar locations to other forms of androgen-dependent acne such as the lower third of the face, chest, upper arms, and back.

Yeung and colleagues noted that previous studies of acne in transmasculine persons have featured limited data from single0center retrospective cohort or self-reported survey studies. A recent, large, single-center study from Boston found that the prevalence of acne increased from 6.3% before testosterone therapy to 31.1% after initiating testosterone for an average of 3.4 years in transmasculine patients.

Testosterone-induced acne could be severe and persistent in transmasculine persons, with 28% of transmasculine persons having reported a history of moderate-to-severe acne and 14% having reported current moderate-to-severe acne in a survey of 346 patients across Kaiser Permanente health systems.

Additionally, 66% of transmasculine persons diagnosed with moderate-to-severe acne associated their acne with testosterone therapy.

Assessment and Treatment Plans

Crucially, Yeung and investigators noted that many transgender patients have experiences negative healthcare experiences such as being misgendered, denied care, or harassment within healthcare settings.

Transgender men are also more likely than transgender women to avoid health care due to anticipated discrimination. A lack of knowledge in transgender health care from providers, inadequate insurance coverage, socioeconomic barriers, and healthcare system barrier have been cited as additional obstacles to appropriate care.

Investigators cited inclusive intake forms that do not assume cisgender identity or heteronormativity, gender-neutral or all-gender restrooms available, posting non-discrimination policies as important efforts to create an inclusive environment that cultivates therapeutic relationships.

Gender-inclusive terminology that could aid in facilitating discussions was also recommended.

Currently, there is no evidence-based guideline on the best practices for treating hormonal acne associated with testosterone therapy.

Despite this, topical retinoids such as adapalene, tretinoin, tazarotene, and trifarotene, are indicated for the treatment of both mild to moderate comedonal and inflammatory acne.

Recommendations of topical antibiotics such as clindamycin and erythromycin were also included, though investigators added that limiting the use of topical antibiotics to 12 weeks was preferred.

Regarding moderate-to-severe acne treatments, oral antibiotics, spironolactone, and hormonal contraceptives such as combined oral contraceptive (COC) pills were cited by investigators, though they added that some patients avoid these pulls due to concerns of potential feminizing effects, risk of spontaneous bleeding, and potential adverse event such as nausea and weight gain.

Yeung and colleagues felt that dermatologists should continue to learn along with their transmasculine patients about how to optimize skin, mental health, and quality-of-life outcomes of gender-affirming testosterone therapy.

“Dermatologists have an important role in advocating for comprehensive and culturally competent healthcare that the transgender population deserve,” the team wrote.

The study, "Treating Acne in Transgender Persons Receiving Testosterone: A Practical Guide," was published online in The American Journal of Clinical Dermatology.