‘We can do a much better job’: Initiating acne care for gender-diverse patients
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Key takeaways:
- Acne is common and persistent among transgender patients undergoing testosterone therapy.
- Dermatologists must provide thoughtful and comprehensive acne care.
SAN DIEGO — Acne is common, iatrogenic and impactful to gender-diverse patients receiving gender-affirming care such as testosterone and should not be treated as a “transient rite of passage,” according to a speaker here.
The impact of acne on gender-diverse people is underappreciated, and transgender patients with acne want clinicians to provide clear guidance and initiate care, Howa Yeung, MD, MSc, assistant professor of dermatology at Emory University School of Medicine, said during a presentation at the American Academy of Dermatology Annual Meeting. Yeung, who spoke during a special session on LGBTQ health in dermatology, said dermatologists must go beyond the AAD guidelines to consider additional acne triggers and long-term acne treatments for these patients, who often report symptoms for many years.
“There is no clear guidance and it is trial and error for these patients, asking friends, family or the internet,” Yeung said. “We need to do a better job as dermatologists. How can we treat this early acne and even prevent acne for our patients?”
In some parts of the country, particularly where access to gender-affirming care is very difficult, patients are “so grateful to receive hormone therapy” that they may not want to bring up seemingly lesser issues, such as acne, Yeung said.
“If [patients] do not want to talk to providers about negative side effects, they worry they will be dismissed or that perhaps [the clinician] will take that hormone therapy away,” Yeung said. “If we initiate the acne care, we can do a much better job of providing care to patients.”
Impact of hormone therapy on acne
For transgender accessing gender-affirming care, acne can be common within the first 6 months of initiating testosterone therapy, and available information about acne wrongly suggests the maximal effects occur within 1 to 2 years, Yeung said.
“Acne does not just disappear after 2 years,” Yeung, who is also a co-author of recent the AAD acne guidelines, said. “If that were the case, we would never have to see cisgender adolescents again after 2 years. That does not happen. Unfortunately, the figures still suggest this. It gives a lot of false reassurance to our patients and discourages them from getting care.”
In an analysis of patients receiving masculinizing hormone therapy at Fenway Health in Boston published in 2021 in JAMA Dermatology, researchers reported that 31% of the 988 patients had a diagnostic code of acne, including 19% within 1 year. Younger age at testosterone initiation was noted as a key risk factor, Yeung said.
“This has been replicated across studies. The true incidence of acne is likely even higher,” Yeung said. “We need to recognize that acne is very common in our transmasculine patients, and it does not just go away.”
Consider other acne causes
Dermatologists should also consider other elements of gender-affirming care that can cause acne, Yeung said. For example, patients who are transmasculine or nonbinary but assigned female sex at birth may use a chest binder to reduce the appearance of breast tissue and improve self-esteem, mental health and safety in public. However, soft tissue effects, such as acne, can be common in the truncal region with the use of chest binders, Yeung said.
“The incidence of acne increases over time; the median incidence of acne is within 4 months of wearing a chest binder,” Yeung said. “And the prevalence is different for people. Some are more prone to this physical form of acne.”
“We need to talk to our patients about what type of chest binder they use, something that is breathable and does not cause a lot of occlusion,” Yeung said.
Importantly, acne can have a profound impact on a person’s mental health, Yeung said, but those effects vary widely. Some patients will leverage acne as a “resilience factor,” Yeung said — visible proof that the testosterone therapy they are using is “working.”
“But that does not completely waive our obligation to get that acne treated,” Yeung said.
Benefits of isotretinoin
Among acne treatments, isotretinoin in particular is effective for transgender patients with moderate to severe acne, but concerns about the drug remain, Yeung said. Data suggest isotretinoin may be linked with psychiatric disturbances, including subtle mood changes and idiosyncratic mood symptoms.
Yeung cautioned that any mental health risks that have been reported with isotretinoin should not bar transgender patients as candidates for the therapy, noting that access to needed gender-affirming care sharply reduces any mental health symptoms.
“There are some dermatologists out there who would never prescribe isotretinoin to patients who have a history of depression or suicidal thoughts,” Yeung said. “Guess what? Most of my transgender patients had a history of depression or suicidal ideation. Why? Because they were not getting gender-affirming treatment. Once they get that gender-affirming treatment and have access to appropriate mental health care, they are in a very stable mental health space to go on isotretinoin. If we just exclude all these patients from effective therapy, we are perpetuating structural transphobia.”
Instead, patients interested in isotretinoin therapy should receive multidisciplinary care that includes monthly dermatology visits, a depression screening, assessment for pregnancy potential, contraceptive counseling and lab monitoring, as well as longitudinal mental health care.
“Remember: sexual behavior is different from gender identity,” Yeung said. “We need to assess the sexual behavior our patients take part in. For those sexually active with people who are sperm producing, there are helpful options for contraception. Most of my patients prefer an IUD, a shot or an implant. Working with a reproductive health specialist who knows how to work with transgender patients is important.”
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Yeung H, et al. S054 LGBTQ/SGM health in dermatology: essentials and updates. Presented at: American Academy of Dermatology Annual Meeting; March 8-13, 2024; San Diego.
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