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FEATURE ARTICLES

Acne Management in Transgender Men and Boys

Somers, Kathryn; Greenberg, Katherine

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Journal of the Dermatology Nurses’ Association: 11/12 2021 - Volume 13 - Issue 6 - p 316-318
doi: 10.1097/JDN.0000000000000651
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Abstract

BACKGROUND

Estimates of the American transgender population have significantly increased in recent years with a 2017 best estimate of one in 250 adults, or roughly one million people (Meerwijk & Sevelius, 2017). As transgender people are seeking healthcare, including hormonal therapy, in record numbers (Chen et al., 2016), it is crucial that dermatology offices are able to provide affirming care to transgender patients, including the management of dermatologic side effects from hormonal therapy. The major cutaneous complication of hormonal therapy is the development of acne in transgender men and boys treated with testosterone. Herein, we will discuss management strategies for testosterone-related acne in transgender men and boys.

The word “transgender” refers broadly to people whose gender identity, or sense of self, is different from their sex assigned at birth, which is assigned by others based on presumed hormonal and genetic milieu. “Transgender” as an identity contains many more individual, diverse identities; this article will focus on the care of transgender men and boys who are assigned female at birth and have a male gender identity. Many transgender people use names and pronouns that are different than those assigned at birth and may have identity documents, including insurance cards, that retain their birth name and sex (James et al., 2016). For that reason, we suggest that front desk staff confirm a patient's identity using their last name and date of birth and that healthcare providers routinely ask patients which name and pronouns they would like to use in a clinical interaction. Many more guidelines and trainings are available for healthcare teams wishing to improve the psychosocial experiences of their transgender patients (National LGBT Health Education Center: A Program of the Fenway Institute, 2016).

HORMONAL THERAPY WITH TESTOSTERONE

Statistics suggest that, although most transgender people in the United States desire transition-related healthcare services, only about half have access to hormone therapy (James et al., 2016). Many transgender men and boys utilize testosterone intramuscularly, subcutaneously, or topically, with a goal of undergoing body masculinization including beard growth, chest hair growth, voice deepening, and increased muscularity, although the degree of each of these varies by individual (Hembree et al., 2017). This process typically unfolds over the first 2 years of testosterone therapy. However, even after achieving peak masculinization, testosterone is often a lifelong medication. One adverse consequence of testosterone therapy is the development or worsening of acne (Turrion-Merino et al., 2015). Testosterone is locally converted to the more potent dihydrotestosterone by 5-alpha-reductase and can then exert its effects on sebocytes. These effects include sebum production, keratin shedding, Cutibacterium acnes proliferation, and inflammation, all of which can lead to acne production (Motosko et al., 2019). Multiple studies have shown that acne peaks within 4 months after testosterone initiation, sometimes with improvement within the first year (Motosko et al., 2019; Wierckx et al., 2014).

ACNE TREATMENTS

As a patient begins or increases the therapeutic dose of testosterone, acne can be an immediate or delayed side effect. When patients present for dermatologic care, it is important that dermatology providers recognize that masculinizing hormone treatment can be critical for the patient's sense of self and overall well-being (Hughto & Reisner, 2016). Patients should not be told to stop their hormone therapy but should rather be supported with additional acne management. For mild acne, it is reasonable to start with typical treatments such as benzoyl peroxide and a topical retinoid. A 3-month course of oral antibiotics such as doxycycline may also be helpful.

Hormonal acne treatments should be used with great caution and only in full conversation with the patient and their individual goals of care. Estrogen-containing contraceptive methods including oral contraceptive pills would not be an initial acne management choice for transgender men as they are often avoided because of concerns about interactions between estrogen and testosterone (Deutsch, 2016). However, guidelines for transmasculine contraception include the safe use of combined hormonal methods; this acne treatment option could be explored if needed in consultation with the patient and their hormone-prescribing provider using expert guidelines (Bonnington et al., 2020). Spironolactone is another agent often used with great success in treatment of cisgender women with acne; however, its antitestosterone effects might counteract the effects of testosterone therapy. There are no high-quality studies examining the effects of combined hormonal or antiandrogenic treatments on acne in transgender men.

The mainstay of treatment for severe acne in transgender men, as in patients of all genders, is isotretinoin. If the patient is premenopausal and still retains his uterus and ovaries, this means registering with the iPledge program as a “female of child-bearing potential” and taking monthly pregnancy tests. We agree with the movement asking for iPledge to change its nomenclature to more accurately document the gender identities of individuals using isotretinoin and to provide more affirming care for transgender individuals. As the program currently stands, it requires dermatology providers to take a sensitive and affirming sexual history to determine an individual patient's pregnancy risk (Singer & Keuroghlian, 2020).

IPLEDGE PROGRAM

The iPledge program requires two forms of birth control or abstinence. Transgender men may have sex with partners of all genders, as sexual orientation is independent of gender identity, therefore using sexual practices that may or may not have the potential to create a pregnancy. Therefore, when considering isotretinoin, the dermatology provider should ask patients about the genders of their partners and the potential for their current or future sex practices to create a pregnancy. If patients are sexually active only with partners assigned female at birth, or are not having penetrative intercourse with partners assigned male at birth, abstinence may be used as a form of contraception. If patients are having penetrative sex with partners capable of producing sperm, we recommend comprehensive contraceptive counseling as outlined by the Society for Family Planning guidelines (Bonnington et al., 2020). Our typical practice is to recommend a progesterone-only intrauterine device or subdermal implant, both of which are highly effective, have very low doses of synthetic progesterone, and avoid estrogen for transgender men concerned about the addition of female hormonal medications (Deutsch, 2016). Progesterone-only pills are highly ineffective contraception with typical use and are not allowed by the iPledge program. If transgender male patients are comfortable taking estrogen containing combined hormonal contraceptive methods, and for whom there is no estrogen contraindication, then combined oral contraceptive pills, the patch, or the ring can be considered. There is insufficient evidence to discuss the potential effects of exogenous estrogen on masculinization in transgender men on testosterone. Testosterone therapy does not reliably suppress ovulation and is not considered a contraceptive method (Bonnington et al., 2020).

LABORATORY MONITORING

Isotretinoin and testosterone can both cause derangements in the lipid profile, particularly triglycerides (Hansen et al., 2016; Hembree et al., 2017). Liver dysfunction has been occasionally reported on isotretinoin but is rare with intramuscular and topical testosterone (Hansen et al., 2016; Hembree et al., 2017). We suggest monthly monitoring with a lipid panel and hepatic panel until laboratory results have proven normal on the highest planned isotretinoin and testosterone doses.

RISK OF ACNE FULMINANS

Transgender men and boys on both testosterone and isotretinoin are at an increased theoretical risk of acne fulminans, a sudden and severe worsening of acne. Isotretinoin and testosterone treatments are both independent risk factors for acne fulminans (Greywal et al., 2017). Our own clinic has now treated two transgender men with acne fulminans; one case developed when starting isotretinoin in the setting of long-standing testosterone therapy, and the other developed with a dose increase in testosterone therapy not on isotretinoin. Caution should be exercised when using the combination together. If the patient's acne is nodulocystic on baseline dermatologic evaluation, we will typically start with an isotretinoin dose of 10 mg daily for the first month and often also prescribe a month-long prednisone taper simultaneously (starting at 40 mg and tapering by 10 mg each week) to prevent a flare (Greywal et al., 2017). If there were no acne flare, we would then prescribe another month of isotretinoin 10 mg daily, this time without any prednisone. If tolerated, we would increase each month until reaching a goal of 1–1.25 mg/kg per day. It is prudent to start with a low dose of isotretinoin and steadily increase the dosage as tolerated to a high cumulative dose (greater than 220 mg/kg; Blasiak et al., 2013), as patients on testosterone may be at a high risk for relapse after discontinuing isotretinoin. As a result, many of our transgender male patients end up on longer-than-typical isotretinoin courses, with some as long as 9–12 months.

CONCLUSION

Testosterone hormone therapy can induce acne, which is typically mild and may self-resolve after the first 12 months of therapy (Motosko et al., 2019; Wierckx et al., 2014). However, transgender men and boys also have the potential to develop severe, scarring acne. Painful and disfiguring acne can make medical transition significantly more difficult. Dermatology practitioners are in the fortunate position of being able to support transgender men undergoing gender-affirming hormone therapy via the mitigation of this unwanted side effect.

REFERENCES

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Keywords:

Acne; Transgender; LGBT; Isotretinoin

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