Treating Acne in Patients Who Desire Gender-affirming Hormone Therapy
Acne is one of the most common reasons patients seek dermatologic care globally. Hormonal acne specifically, is a common adverse effect of exogenous or external testosterone therapy. It is common for patients who desire gender-affirming masculinizing hormone therapy to be prescribed testosterone. In this article, I review a study titled, "Treating Acne in Transgender Persons Receiving Testosterone: A Practical Guide," by Radi et al. (2022). Additionally, I created a downloadable infographic on testosterone-induce acne treatment considerations for you to use at your practice site.
The Burden of Adult Acne
Adolescents and adults find acne to be physiologically and psychologically stressful, negatively impacting their quality of life. I would argue adult acne is even more burdensome due to the common misconception that acne is a teenage problem. While teenagers may find some comfort in their peers also living with acne, our transgender patients can find it to be isolating and nearly unavoidable once they begin testosterone therapy. More than 60% of patients with moderate to severe acne believed their acne was caused by testosterone therapy. Testosterone therapy can be lifelong for patients who desire to maintain the masculinizing benefits. It’s been reported that even after ten years of treatment, patients will continue to have mild (63%) or moderate (6%) acne which speaks to the importance of the study by Radi et al (2022).
Before We Continue
Resources
Learn about health equity for the LGBTQIA+ community here:
The list below is by no means all inclusive. It is meant to explain a few terms mentioned in this article to support your understanding as you read along and help you take those beginning steps to learning more.
- Body dysmorphia - a mental health condition where a person spends a lot of time worrying about flaws in their physical appearance
- Cisgender - gender identity is the same as gender assigned at birth
- Gender-affirming treatment – used to help someone physically look more like the person they feel like on the inside
- Gender identity – the internal sense someone has being a certain gender
- Trans – a term used among transgender people to refer to one another
- Transgender – gender identity or gender expression is different from sex assigned at birth
- Transmasculine – someone assigned female at birth who now identifies as transgender male or gender non-binary
- Transfeminine - someone assigned male at birth who identifies as transgender female or identify with femininity
Testosterone (T) Therapy
Some common reasons patients may desire testosterone:
- Transgender men and women: gender-affirming masculinizing hormone therapy
- Cisgender women: to increase sex drive
- Cisgender men: to improve under active testosterone hormone development
Hormonal Acne
Acne is a chronic inflammatory disorder of the pilosebaceous follicle (the hair shaft, hair follicle, and sebaceous gland). Acne can cause comedones, papules, pustules, nodules, and scarring. It can be triggered by hormones, inflammation, stress, comedogenic (likely to block pores) hair and skin care products, the occlusion of binders, and medications like testosterone which cause an over production of sebum or oil. In contrast, estrogen decreases the production of sebum (oil). Hormonal acne is commonly found on the lower face, chin, and jawline. In patients taking testosterone, it can be found on the lower third of the face, chest, back and upper arms.
Testosterone-induced Acne
Patients receiving testosterone are likely to experience testosterone-induced acne in the first two years of therapy. It is good practice to help manage expectations by letting your patients know testosterone-induced acne tends to occur in the first six months. Then reassure them if they maintain their skin regimen, they can likely expect noticeable improvement around 12 months. Testosterone-induced acne tends to be more severe and persistent, and studies suggest it may occur at a higher rate amongst younger patients.
Barriers to Care
It’s been well documented that our LGBTQIA+ patients have some of the poorest health outcomes, highest rates of anxiety and depression, some of the highest rates of suicide, and often avoid seeking medical treatment until their health has progressively worsened. Patients have been misgendered, denied, care and harassed by medical professionals. While there are a number of factors that would explain the negative patient experiences documented in the literature, there is also a lack of knowledge and training amongst healthcare providers. Additionally, transgender men and transgender women are not properly represented in clinical trials and we have not done enough documenting of gender-affirming hormone therapy in research. Therefore, there are no specific treatment guidelines for transgender men and women that take into account their unique needs and therapy goals. This paucity in data presents an opportunity for aspiring Dermatology Nurse Practitioners, Doctor of Nursing Practice students, and entrepreneurs interested in creating a practice model, conducting future research, and/or offering a niche service line.
Treatment Recommendations
I’ve highlighted a few important reminders for common acne therapy that will help you to provide more culturally competent care for your patients who are candidates for testosterone and desire gender-affirming hormone therapy. Below is an infograph on Testosterone-induced acne treatment considerations. I created it for you to display or keep handy at your practice site. You can download a copy or take a screenshot and let me know the feedback you receive from your colleagues as well as how you plan to implement it into your practice.
Topical retinoids
o Trifarotene has been approved for truncal acne
o Discuss teratogenic effects and strict adherence to a contraceptive plan
Topical antiandrogen
o May be an alternative to testosterone that doesn’t cause acne
Oral antibiotics
o Discuss teratogenic effects as applicable
Oral contraceptives
o Testosterone is not a contraindication for oral contraceptives
o Transmasculine patients should be informed of risk of feminizing effect: irregular bleeding, breast tenderness, nausea, and weight gain
o Oral contraceptives may help patients who desire gender-affirming hormone therapy achieve amenorrhea
o Consider consulting or referring patients to a reproductive health specialist to help them create a personalized contraceptive treatment plan
Spironolactone
o Data suggests spironolactone is highly efficacious at treating hormonal acne in cisgender women
o Transmasculine patients should be informed of risk of feminizing effect: irregular bleeding, breast tenderness, and gynecomastia
Isotretinoin
o Data suggests isotretinoin is highly efficacious at treating moderate to severe acne in transmasculine patients
o Discuss teratogenic effects and strict adherence to a contraceptive plan, frequent monitoring, and registration with iPLEDGE
o iPLEDGE registration requires patients to identify as a patient who can become pregnant (PWCBP) or as a patient who cannot become pregnant
o PWCBP must agree to monthly contraceptive counseling, pregnancy monitoring, and abstinence with sperm-producing partners or the strict utilization of two types of contraception
o Isotretinoin can cause delayed wound healing 6 to 12 months after cessation of treatment
o Consider delaying acne treatment if patient is planning to have gender-affirming surgery to optimize aesthetic outcomes
o Consider aggressive treatment plan for moderate to severe truncal acne that has potential to cause scarring, negatively impairing aesthetic outcomes following gender-affirming surgery
o Educate patient and monitor for increased risk of anxiety, depression, and suicidality.
30 Article Challenge
This blog post is part of a series I posted on Instagram where I read and review articles related to dermatology and discuss the implications for dermatology nurse practitioners. The archived posts can be found on my Instagram page in the highlights listed below. I’ll continue to update the highlights as I review more articles.
Stay tuned for the next article on how to build an inclusive practice. If you have any feedback, practice pearls, or know about current clinical trials that relate to the topic of gender-affirming hormone therapy, please message me, I would love to continue the conversation.
References
Gao, J., King, D., Modest, A., & Dommasch, E. (2022). Acne risk in transgender and gender diverse populations: retrospective, comparative cohort study. The Journal of the American Academy of Dermatology, 87(5), P1198-1200. https://doi.org/10.1016/j.jaad.2022.03.013
Radi, R., Gold, S., Acosta, J., Barron, J., & Yeung, H.(2022). Treating acne in transgender persons receiving testosterone: A practical guide. American Journal of Clinical Dermatology, 23, 219-229. https://doi.org/10.1007/s40257-021-00665-w
Kimberly Madison, DNP, AGPCNP-BC
Kimberly Madison is a new dermatology nurse practitioner with a passion for writing, entrepreneurship, financial literacy, and mentorship. I created this blog to share my journey as I become a dermatology nurse practitioner and entrepreneur. Most importantly, I’m looking forward to helping nurse practitioners and aspiring students to better understand the business of dermatology and their role to improving access to care, providing culturally competent care, and advancing education.
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