Moderate-to-Severe Acne and Mental Health Symptoms in Transmasculine Persons Who Have Received Testosterone

Isotretinoin for Acne in Transgender and Gender-Diverse Individuals Receiving Masculinizing Hormone Therapy

Importance

Masculinizing gender-affirming hormonal therapy is associated with the development of acne. While isotretinoin is a highly effective acne treatment, little is known about its effectiveness and safety among transgender and gender-diverse individuals receiving gender-affirming hormonal therapy.

Objective

To evaluate clinical outcomes of isotretinoin among transgender and gender-diverse individuals receiving gender-affirming hormonal therapy.

Design, Setting, and Participants

This multicenter retrospective case series study was conducted at 4 medical centers: Mass General Brigham, University of Pennsylvania, Emory University, and Fenway Health. It included patients aged between 12 and 49 years who were receiving masculinizing gender-affirming hormonal therapy and prescribed isotretinoin for the management of acne between August 14, 2015, and September 20, 2023.

Exposure

Isotretinoin therapy for the management of acne.

Main Outcomes and Measures

The percentage of patients experiencing improvement or clearance of acne, as well as rates of acne recurrence. Adverse effects and reasons for treatment discontinuation were also evaluated.

Results

Among 55 included patients, the mean (SD) age was 25.4 years; 4 (7.3%) were Asian, 2 (3.6%) were Black, 4 (7.2%) were Hispanic, 1 was (1.8%) multiracial, and 36 (65.5%) were White. The median isotretinoin course duration was 6 months (IQR, 4.0-8.0), with a median cumulative dose of 132.7 mg/kg (IQR, 66.4-168.5); the cumulative dose was less than 90 mg/kg for 16 patients (29.1%) and less than 120 mg/kg for 22 patients (40.0%). Isotretinoin was associated with improvement in 48 patients (87.3%) and clearance in 26 patients (47.3%). For the 33 patients treated with a cumulative dose of 120 mg/kg or more, these rates increased to 32 patients (97.0%) and 21 patients (63.6%), respectively. Among the 20 patients who achieved acne clearance and had any subsequent health care encounters, the risk of recurrence was 20.0% (n = 4). The most frequently reported adverse effects were dryness (n = 44; 80.0%), joint pain (n = 8; 14.5%), and eczema (n = 5; 9.1%). Laboratory abnormalities were uncommon. Reasons for premature treatment discontinuation included cost, pharmacy issues, adverse effects, logistical reasons (scheduling), and wound healing concerns for gender-affirming surgery.

Conclusion and Relevance

In this case series study of individuals with acne who were receiving masculinizing gender-affirming hormonal therapy and underwent isotretinoin treatment, isotretinoin was often effective and well tolerated. However, premature treatment discontinuation was common and associated with poorer outcomes. Further efforts are needed to understand optimal dosing and treatment barriers to improve outcomes in transgender and gender-diverse individuals receiving masculinizing gender-affirming hormonal therapy.

Guidelines of care for the management of acne vulgaris

BACKGROUND

Acne vulgaris commonly affects adults, adolescents, and preadolescents aged 9 years or older.

OBJECTIVE

The objective of this study was to provide evidence-based recommendations for the management of acne.

METHODS

A work group conducted a systematic review and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach for assessing the certainty of evidence and formulating and grading recommendations.

RESULTS

This guideline presents 18 evidence-based recommendations and 5 good practice statements. Strong recommendations are made for benzoyl peroxide, topical retinoids, topical antibiotics, and oral doxycycline. Oral isotretinoin is strongly recommended for acne that is severe, causing psychosocial burden or scarring, or failing standard oral or topical therapy. Conditional recommendations are made for topical clascoterone, salicylic acid, and azelaic acid, as well as for oral minocycline, sarecycline, combined oral contraceptive pills, and spironolactone. Combining topical therapies with multiple mechanisms of action, limiting systemic antibiotic use, combining systemic antibiotics with topical therapies, and adding intralesional corticosteroid injections for larger acne lesions are recommended as good practice statements.

LIMITATIONS

Analysis is based on the best available evidence at the time of the systematic review.

CONCLUSIONS

These guidelines provide evidence-based recommendations for the management of acne vulgaris.

Lived Experience of Acne and Acne Treatment in Transgender Patients

Importance

While acne is common in transgender and gender-diverse people and is associated with gender-affirming hormone therapy, little research has examined these factors and their impact in gender minority groups.

Objective

To examine the lived experiences of acne and acne treatment in transgender and gender-diverse participants.

Design, Setting, and Participants

This mixed-methods analysis was conducted at a multidisciplinary gender center at a public safety-net hospital and endocrinology and dermatology clinics at a tertiary academic center from January 4, 2021, to April 7, 2022, using semistructured interviews and surveys. Participants were transgender or gender-diverse adults who had received gender-affirming hormone therapy. Data analysis was performed from November 11, 2021, to March 31, 2023.

Exposure

Current diagnosis of acne.

Main Outcomes and Measures

Interviews exploring the experience of acne and acne treatment were audio recorded, transcribed verbatim, coded using minority stress theory and the socioecological model, and analyzed using thematic analysis. Themes were triangulated with survey data on gender, self-reported acne severity, skin-specific quality-of-life impact, and treatment experience.

Results

A total of 32 participants were included in the study (mean [range] age, 32 [18-57] years; 17 transgender men, 11 transgender women, and 4 nonbinary participants). Ten participants (31%) self-rated their skin as currently clear or almost clear, 11 (34%) reported mild acne, and 11 (34%) had moderate to severe acne. Participants described experiences of rejection and bullying related to acne and admitted avoiding social interactions in which they anticipated acne-related discrimination, which led to feelings of depression and anxiety. Acne worsened body appearance dissatisfaction. Transgender women reported acne interfering with feminine gender expression. Transgender men often normalized acne development, sometimes viewing acne positively as an early sign of testosterone action. Most participants tried over-the-counter acne treatments and commonly sought acne treatment advice from physicians, peers, online forums, and social media. Barriers to acne treatments included cost, lack of multidisciplinary care, mistrust toward the health care system, and lack of transgender-specific acne care education.

Conclusions and Relevance

In this mixed-methods study, transgender and gender-diverse individuals reported experiencing acne-related stigma and facing barriers to acne treatment. Multilevel changes, such as developing strategies to reduce acne stigma, providing transgender-specific acne care education, facilitating multidisciplinary acne care, and expanding transgender-friendly clinical environments, are recommended to reduce the impact of acne in transgender individuals.

Incidence and Factors Associated With Acne in Transgender Adolescents on Testosterone: A Retrospective Cohort Study

OBJECTIVE

This retrospective cohort study aimed to assess incidence and predictors of acne among transgender adolescents receiving testosterone.

METHODS

We analyzed records of patients aged <18 years, assigned female at birth, seen at Children's Healthcare of Atlanta Pediatric Endocrinology clinic for testosterone initiation between January 1, 2016, and January 1, 2019, with at least 1-year follow-up documented. Bivariable analyses to determine the association of clinical and demographic factors with new acne diagnosis were performed.

RESULTS

Of 60 patients, 46 (77%) did not have baseline acne, but of those 46 patients, 25 (54%) developed acne within 1 year of testosterone initiation. Overall incidence proportion was 70% at 2 years; patients who used progestin prior to or during follow-up were more likely to develop acne than nonusers (92% vs 33%, P <.001).

CONCLUSION

Transgender adolescents starting testosterone, particularly those taking progestin, should be monitored for acne development and treated proactively by hormone providers and dermatologists.

Characterizing Dermatological Conditions in the Transgender Population: A Cross-Sectional Study

Purpose

This study aimed to demonstrate the effects of gender-affirming hormone therapy (GAHT) and gender-affirming procedures on the skin in transgender individuals.

Methods

We conducted a cross-sectional study among transgender people. Skin conditions related to GAHT were assessed, including acne (using the Investigator's Global Assessment, IGA), postacne sequelae, melasma, hypertrichosis in androgen-sensitive areas (HAAs) in transgender men (TM) and hirsutism in transgender women (TW) (using the modified Ferriman-Gallwey score, mFG score), and hair loss (using the Hamilton-Norwood and Ludwig scale) at baseline, 6 months after GAHT, and the day on which the questionnaire was completed. Dermatological problems after gender-affirming procedures were evaluated.

Results

A total of 159 patients, including 134 TM and 25 TW, were eligible to participate. The median duration of GAHT was 23 and 36 months in TM and TW, respectively. In TM, the median IGA score of facial acne increased from 1 at baseline to 3 after 6 months and decreased to 2 after 2 years of GAHT. The mFG score indicated HAA in all TMs after testosterone treatment. A total of 88.1% of TM had no hair loss before hormone therapy. However, after 2 years of GAHT, 76.1% of TM developed male pattern hair loss (MPHL), and 26.1% of them had moderate-to-severe MPHL. In TW, the median IGA and mFG scores decreased after 3 years of hormone therapy, and the proportion of female pattern hair loss (FPHL) in TW increased to 16% after GAHT. In both groups, the most common skin complication after gender-affirming surgery was hypertrophic scarring.

Conclusions

GAHT in TM resulted in acne and MPHL, whereas GAHT in TW caused melasma and FPHL.

Evaluation of the efficacy and relapse rates of treatment protocols for moderate acne using isotretinoin based on the global acne grading system: Randomized, controlled, comparative study

Protocols for treating acne with isotretinoin have varied widely because some factors associated with relapse and treatment duration have not yet been fully determined. This paper evaluates the effectiveness of conventional, low, and intermittent isotretinoin dosage protocols in the treatment of moderate acne and investigates the relationships between GAGS score, treatment duration and relapse rate. The 107 patients with moderate acne were randomly divided into three groups who received isotretinoin for 24 weeks (Group A: 0.5-1 mg/kg/day; Group B: 0.25-0.4 mg/kg/day; Group C: 0.5-0.7 mg/kg/day for 1 week out of every 4 weeks). The results show that both conventional and continuous low doses achieved full clinical effectiveness with minimum relapse rates. However, fewer side effects and better patient satisfaction were reported with the low dose. Significant differences in GAGS scores after 24 weeks were found between groups B and C (p = 0.037) and between groups A and C (p < 0.001), while no significant differences were found between groups A and B (p = 0.153). It was observed that relapse rate increased with initial GAGS score. The average relapse rate was 58.0% for those with initial GAGS scores of 25-30 compared with 5.5% for those with scores of 19-24. It was also noticed that, among the patients who relapsed, the highest percentage (56.3%) were in the age group <20 years. However, GAGS (β = 0.646, t = 8.323, p < 0.001) was found to be a better predictor of relapse than age (β = 0.083, t = 1.073, p = 0.286). These results suggest that initial GAGS score is an important factor in determining the treatment protocol for moderate acne. Furthermore, this study recommends that a low-dose treatment is most suitable when GAGS <25, as it can achieve complete clearance of acne with minimal relapses and side effects.

Management of acne in transgender and gender diverse youth part 1: Gender affirming care and risk factors for the development of acne

Acne vulgaris is among the most common skin disorders afflicting adolescents worldwide, and though well-established guidelines of care exist for acne management, these guidelines do not uniformly consider or address the unique psychosocial and medical needs of transgender and gender diverse (TGD) youth. TGD youth may possess distinct goals of therapy when treating their acne; the use of medicines routinely employed to treat acne may also expose TGD adolescents receiving gender affirming medical therapy to greater risk of adverse events. Part 1 of this two-part review provides dermatologists an understanding of gender affirming care and its timing, as well as its potential impacts on the development of acne in TGD youth.

Management of acne in transgender and gender diverse youth Part 2: Unique considerations and strategies in medical treatment

Acne vulgaris is among the most common skin disorders afflicting adolescents worldwide, and though well-established guidelines of care exist for acne management, these guidelines do not uniformly consider or address the unique psychosocial and medical needs of transgender and gender diverse (TGD) youth. Part 2 of this two-part review provides guidance on a stepwise approach to the medical treatment of acne in TGD youth, with an emphasis on safety, efficacy, and the delivery of medical care in a culturally humble, thoughtful, and gender-affirming manner.

Managing Dermatologic Effects of Gender-Affirming Therapy in Transgender Adolescents

Transgender adolescents seek gender-affirming medical care to address gender identity and incongruence. Improved understanding of the dermatologic impact of gender-affirming medical care such as pubertal suppression, hormone therapy, and surgeries can enhance patient outcome. Pubertal suppression treats dysphoria associated with development of secondary sex characteristics, including androgen-driven acne. Gender-affirming hormone therapy influences acne and hair development in transgender adolescents. Dermatologists can help manage skin effects associated with chest binding and gender-affirming hormone therapy and surgery. Provision of patient-centered gender-affirming care in dermatologic and multidisciplinary settings is essential to improve skin and overall outcomes of gender-affirming therapy.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Treating Acne in Transgender Persons Receiving Testosterone: A Practical Guide

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 significant impact on quality of life in transgender patients. Specific training and awareness are needed for a clinically and culturally competent encounter while providing care for the transgender patient. 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.