madman
Super Moderator
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 a significant impact on the quality of life in transgender patients. Specific training and awareness are needed for a clinically and culturally competent encounter while providing care for transgender patients. 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, and overall approach to acne care and terminologies, management for mild to severe acne, and specific considerations for isotretinoin.
1.1 Terminology and Definitions
2 Epidemiology and the Impact of Acne in Transgender Persons
3 Clinical Guidance and Overall Approach to Care
4 Anatomic Inventory, Sexual History Taking, and Reproductive Potential Assessment
5 Treatment Plan
5.1 Mild Acne Treatments
5.1.1 Topical Retinoids
5.1.2 Topical Benzoyl Peroxide and Topical Antibiotics
5.1.3 Topical Antiandrogen
5.2 Moderate to Severe Acne Treatments and Contraceptive Considerations
5.2.1 Oral Antibiotics
5.2.2 Spironolactone
5.2.3 Hormonal Contraceptives
5.3 Isotretinoin and Multidisciplinary Considerations
6 Conclusion
Acne is common and imposes high social and quality-of-life impacts on transgender patients receiving testosterone. Transgender patients deserve equitable acne care as for their cisgender peers. Culturally competent and comprehensive acne encounters involve inclusive history taking, routine collection of sexual orientation and gender identity data, and patient-centered physical examination. As multiple acne medications may be teratogenic, providers should conduct a thorough assessment of reproductive potential and provide counseling accordingly. While discussing the different contraception options, providers should keep in mind that testosterone therapy is neither reliable contraception nor a contraindication to all other forms of contraception. Acne treatment regimen selection should also consider the patients’ transition goals. When isotretinoin is indicated, providers should discuss iPLEDGE requirements with the patient while building a therapeutic alliance. The clinical encounter should discuss the effects of isotretinoin in a multidisciplinary approach and plans to monitor and alleviate potential adverse effects. Dermatologists should continue to learn with their patients 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 deserves.
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 a significant impact on the quality of life in transgender patients. Specific training and awareness are needed for a clinically and culturally competent encounter while providing care for transgender patients. 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, and overall approach to acne care and terminologies, management for mild to severe acne, and specific considerations for isotretinoin.
1.1 Terminology and Definitions
2 Epidemiology and the Impact of Acne in Transgender Persons
3 Clinical Guidance and Overall Approach to Care
4 Anatomic Inventory, Sexual History Taking, and Reproductive Potential Assessment
5 Treatment Plan
5.1 Mild Acne Treatments
5.1.1 Topical Retinoids
5.1.2 Topical Benzoyl Peroxide and Topical Antibiotics
5.1.3 Topical Antiandrogen
5.2 Moderate to Severe Acne Treatments and Contraceptive Considerations
5.2.1 Oral Antibiotics
5.2.2 Spironolactone
5.2.3 Hormonal Contraceptives
5.3 Isotretinoin and Multidisciplinary Considerations
6 Conclusion
Acne is common and imposes high social and quality-of-life impacts on transgender patients receiving testosterone. Transgender patients deserve equitable acne care as for their cisgender peers. Culturally competent and comprehensive acne encounters involve inclusive history taking, routine collection of sexual orientation and gender identity data, and patient-centered physical examination. As multiple acne medications may be teratogenic, providers should conduct a thorough assessment of reproductive potential and provide counseling accordingly. While discussing the different contraception options, providers should keep in mind that testosterone therapy is neither reliable contraception nor a contraindication to all other forms of contraception. Acne treatment regimen selection should also consider the patients’ transition goals. When isotretinoin is indicated, providers should discuss iPLEDGE requirements with the patient while building a therapeutic alliance. The clinical encounter should discuss the effects of isotretinoin in a multidisciplinary approach and plans to monitor and alleviate potential adverse effects. Dermatologists should continue to learn with their patients 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 deserves.
