Researchers Outline Multifactorial Considerations for Acne Treatment in Transgender Patients Receiving Testosterone

A new article offered guidance for clinicians treating acne in their transgender patients receiving testosterone therapy. As a common side effect of gender-affirming testosterone, acne can significantly impact quality of life by impairing body image and mental health.

Throughout their paper, the researchers highlighted that acne treatment for these patients often involves other considerations, such as reproductive health and mental health. They noted dermatologists should keep these in mind when making decisions for each patient.

“There is no current evidence-based guideline on the best practices for treating hormonal acne in the context of testosterone therapy. Current treatment regimens for hormonal acne have been extrapolated from acne treatment guidelines designed for cisgender persons not receiving testosterone,” explained the researchers.

“Acne treatment planning depends on multiple factors such as the predominant acne lesion type, physician- and patient-assessed severity, presence of post-inflammatory erythema, dyspigmentation or scarring, and psychological distress,” they said.

Treatment options include mild acne treatments, moderate to severe acne treatments and contraceptive considerations, and isotretinoin with multidisciplinary considerations.

Mild acne treatments consist of topical retinoids indicated for mild and moderate comedonal and inflammatory acne, such as adapalene and trifarotene. The latter is the only topical retinoid approved for truncal acne, which the researchers said may be more prevalent in patients with acne stemming from testosterone therapy. Other mild treatments include topical benzoyl peroxide and topical antibiotics, as well as topical antiandrogen, such as clascoterone. While trials of clascoterone have not included transgender individuals, it’s been suggested that the treatment may be able to target unwanted testosterone action in the skin.

Moderate to severe acne treatments include oral antibiotics used for acne covering a large portion of the body, which are recommended for induction use over the first 3 months of treatment before using maintenance treatment. These treatments also include spironolactone, although the researchers warned the treatment may not be appropriate for transgender patients receiving testosterone therapy because it systemically blocks the masculinizing effects of testosterone.

Hormonal contraceptives can offer patients acne treatment while also providing contraception, as patients who still have a functional uterus and ovaries can become pregnant even while receiving testosterone. The researchers emphasized the importance of discussing contraceptive options with a reproductive health specialist to tailor treatment to each patient’s needs.

“As multiple acne medications may be teratogenic, providers should conduct a thorough assessment of reproductive potential and provide counseling accordingly,” wrote the researchers. “While discussing the different contraception options, providers should keep in mind that testosterone therapy is neither a reliable contraception nor a contraindication to all other forms of contraception.”

Isotretinoin, according to the researchers, is feasible and effective in treating moderate-to-severe acne in remission for transmasculine patients. Authors highlighted 2 case series in which the treatment addressed severe testosterone-associated acne. However, in addition to mental health considerations like depression and anxiety, isotretinoin during pregnancy can cause fetal death and severe birth defects, so patients prescribed the treatment must enroll in the FDA’s iPLEDGE program that manages the risks of isotretinoin. The researchers noted that until the tail end of 2021, the program created roadblocks to treatment access.

“Prior to December 2021, iPLEDGE used a gender binary categorization to register patients based on their sex assigned at birth, which led to ethical dilemmas when caring for transgender patients. For some patients, signing the iPLEDGE consent was psychologically traumatic, leading them to forgo acne treatment,” the researchers explained, adding that recent changes to the program use gender-neutral assignment, and may reduce these barriers.

Reference:

Radi R, Gold S, Acosta JP, Barron J, and Yeung H. Treating acne in transgender persons receiving testosterone: a practical guide. Am J Clin Dermatol. Published online January 11, 2022. doi: 10.1007/s40257-021-00665-w