Treating Acne in Transgender Persons Receiving Testosterone: A Practical Guide

Epidemiology and the Impact of Acne in Transgender Persons

Testosterone-induced acne can be severe and persistent in transmasculine persons. For example, 28% of transmasculine persons have reported a history of moderate to severe acne and 14% reported current moderate-to-severe acne in a survey of 346 transmasculine persons across Kaiser Permanente health systems [17]. Moreover, 66% of transmasculine persons diagnosed with moderate-to-severe acne associated their acne with testosterone therapy [17]. Regarding long-term acne, after an average of 10 years of testosterone treatment, 63% of patients still had mild acne while 6% had moderate acne in a small survey of 50 transgender men in Belgium [14]. Nonetheless, transmasculine persons were significantly less likely to see dermatologists than transfeminine persons [17], suggesting access barriers to dermatologist care for transmasculine patients with acne.

Chest binders are sometimes used by transmasculine patients to achieve a more masculine contour and to reduce gender dysphoria. However, excessive skin occlusion, physical compression, and overheating may increase the risks of acne, skin swelling, itching, skin infection, and scarring over the chest and back [18]. A large community-engaged online survey of 1800 transmasculine persons found that acne developed in 33.3 and 48.6% of patients after chest binding for 1 year and 10 years, respectively [18].

In contrast, for transfeminine patients, who were assigned male at birth, feminizing hormone therapy commonly includes estrogen and/or anti-androgens such as spironolactone [7]. Corollary to the use of estrogen-containing contraceptives and spironolactone for the treatment of moderate-to-severe acne in cisgender women, these treatments often improve acne for transfeminine persons [4, 7]. In a large survey of 350 transfeminine persons, transfeminine persons rarely reported current moderate-to-severe acne [17].

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Acne negatively impacts mental health and quality of life in transgender persons receiving testosterone. Transgender and gender non-binary persons are more likely to have mental health comorbidities, such as anxiety or depression [19]. While gender-affirming hormone therapy has been shown to improve quality of life and reduce anxiety and depression symptoms [20], it should not be assumed that their adverse cutaneous effects, such as acne, are transient or innocuous. Subjective severity of acne has correlated directly with symptoms of anxiety and depression [21]. Visible acne lesions or acne scars can be stigmatizing, especially for patients who struggle with body image disorders. For transmasculine patients, acne and acne scars resulting from gender-affirming testosterone therapy might trigger self-image insecurity and body dysmorphia [22]. Notably, some transmasculine adolescents have viewed acne as a concrete sign for physical transition, which required more aggressive treatment, but also acknowledged that topical acne care may trigger dysphoria for some patients due to associated feminine connotations [23]. Recent data showed that transmasculine individuals diagnosed with moderate-to-severe acne were more likely to report clinically significant depression and anxiety symptoms compared with transmasculine persons without moderate-to-severe acne [24]. Notably, 71 and 39% of transmasculine persons with moderate-to-severe acne reported clinically significant depression and anxiety, respectively [24]. Dermatologists, primary care and hormone providers, and mental health providers should be aware of the epidemiology of acne and its associated negative mental health and psychosocial impact to provide timely and comprehensive acne care for transmasculine patients receiving testosterone therapy.

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About the Author: Tung Chi