Acne in Transgender Patients

Transgender persons are individuals whose gender identity or expression diverges from their sex assigned at birth [1]. Many transgender individuals seek gender-affirming therapy to alleviate gender dysphoria and improve mental and overall well-being [2]. Masculinizing hormone therapy (MHT) is a common therapeutic intervention for transgender men (female-to-male) that involves the use of one or several forms of parenteral testosterone [3]. The objective of MHT is to assist the patient in developing male secondary sex characteristics, such as male-pattern hair growth, male body contours, and vocal virilization, while suppressing female secondary sex characteristics [3, 4]. 

Acne is a common adverse event among transgender patients receiving MHT [4, 5, 6]. Studies show that after receiving testosterone, transgender men tend to develop acne in the lower third of the face, chest, upper arms, and back [4, 6]. 

Despite the growing evidence, knowledge on incidence and factors associated with acne among transgender patients receiving MHT is still limited. One recent study by Thoreson et al., investigated the epidemiologic characteristics associated with acne development among a large population of transgender patients over 2 years after initiation of MHT [7]. They found that among 988 transgender patients (median age 28.8 yo) who initiated MHT, there was an overall acne prevalence of 31.1% and a 2-year incidence proportion of 25.1%. They also observed that younger transgender patients (18-21 yo) were more likely to develop acne [7]. 

Thoreson N et al., JAMA Dermatol. 2021 Mar 1;157(3):290-295

In alignment with prior reports, these study findings highlight the need for transgender patients who are considering MHT to be advised on the increased risk of acne and the treatments available. This is important particularly for this group, as both acne and transgenderism are associated with poor quality of life, including higher rates of depression and suicide [8]. 

Currently, well-established clinical practice guidelines on acne management offers little guidance on treating and managing moderate to severe acne in transgender patients [9, 10]. Recent published practical guidelines recommend health care providers to take a multidisciplinary approach for acne management in transgender patients and emphasize the following: 1) create a welcoming and culturally competent environment; 3) consider mental health issues and psychosocial factors that may be impacting quality of life and overall well-being; 3) conduct a gender-inclusive history; and 4) gender-affirming therapy may affect acne presentation, treatment options, and prognosis [4, 11, 12].

It is worth mentioning that estrogen and anti-androgen treatments are gender-affirming hormone therapies for transgender women (male-to-female) that can also lead to various skin conditions [13]. Estrogen reduces facial and body hair growth, changes sweat and odor patterns, decreases sebum production in the skin and stimulates melanocytes [14]. Dermatological conditions such as, facial hirsutism (excessive hair growth on unexpected areas), can lead to pseudofolliculitis barbae (razor bumps), post-inflammatory dyspigmentation or keloid scarring due to shaving and trimming, contributing to gender dysphoria in these patients [15-18]. 

Th number of individuals whose gender identity or expression diverges from their sex assigned at birth, such as transgender patients, is on the rise [8]. This increased in diversity in the average patient presenting to the dermatologist requires a greater understanding of variations in the prevalence, clinical presentation, and optimal treatment approaches to medical and aesthetic dermatologic concerns. Studies investigating the specific clinical and epidemiologic issues and dermatological needs of transgender individuals, such as the one mentioned above, are crucial to help dermatologists and other providers provide the best care possible for all patients. 

References:

1. Yeung H et al., J Am Acad Dermatol. 2019 Mar;80(3):581-589.
2. Coleman E et al., Int J Transgend. 2012:165–232.
3. Nakamura A et al., Endocr J. 2013;60(3):275-81.
4. Radi R et al., m J Clin Dermatol. 2022 Mar;23(2):219-229.
5. Merino-Turrion L et al., JAMA Dermatol. 2015 Nov;151(11):1260-1.
6. Lucky AW et al., Am J Med. 1995 Jan 16;98(1A):89S-94S.
7. Thoreson N et al., JAMA Dermatol. 2021 Mar 1;157(3):290-295
8. Durwood L et al., J Am Acad Child Adolesc Psychiatry. 2017 Feb;56(2):116-123.e2.
9. Zaenglein AL et al., J Am Acad Dermatol. 2016 May;74(5):945-73.e33.
10. Eichenfield FL et al., Pediatrics. 2013 May;131 Suppl 3:S163-86.
11. Ragmanauskaite L et al., Dermatol Clin. 2020 Apr;38(2):219-226.
12. Karasic DH et al., Endocr J. 2013;60(3):275-81.
13. Yeung H et al., Endocrinol Metab Clin North Am. 2019 Jun;48(2):429-440.
14. Stevenson S et al., Clin Interv Aging. 2007;2(3):283-97. doi: 10.2147/cia.s798.
15. Hembree WC et a., J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-3903.
16. Van de Grift TC et al., Arch Sex Behav. 2016 Apr;45(3):575-85.
17. Bridgeman-Shah S et al., Dermatol Ther. 2004;17(2):158-63.
18. Adotama P et al., JAMA Dermatol. 2017 Dec 1;153(12):1325-1326.