Transmasculine patients with acne need specialized care

Key takeaways:

• Acne is often common and severe in transmasculine patients receiving testosterone therapy.
• Care for these patients requires sensitivity to their unique circumstances.

ORLANDO — Treating acne in transmasculine patients requires sensitivity to unique challenges, according to a speaker at the American Academy of Dermatology annual meeting.

“We know that skin disorders may increase body image dissatisfaction,” Erica Dommasch, MD, MPH, assistant professor of department at Harvard Medical School, said during her presentation. “Transgender patients already face high barriers of care, and the transgender population ... is increasing.”

A recent Pew Research study found 1.6% of adults and 5.1% of adults younger than 30 years currently identify as transgender or nonbinary in the United States, she explained.

Acne is an issue prominent in the transmasculine population who are on testosterone therapy, and although most studies have shown acne to be the most severe in the first 6 months of testosterone therapy, Dommasch noted that her patients often have long-term acne.

“I saw some patients that had acne for years, and it was really completely undertreated,” she said. “And as you know as dermatologists, acne can lead to scarring and disfigurement. So, I really encourage people not to wait and see if it gets better. It’s something you really have to treat.”

The most common treatment options for transgender men with severe acne are similar to those used in cisgender men, including topical gels and creams such as clascoterone, oral antibiotics and isotretinoin.

Spironolactone and oral contraceptive pills should be avoided in this population, according to Dommasch.

“They may be options for your gender-queer patients, but for the most part, I have not had any patients really be comfortable with starting those,” she said.

For patients on isotretinoin, special sensitivity to gender identity must be taken as they are evaluated for iPledge enrollment.

Designed to minimize fetal exposure to isotretinoin, iPledge requires all patients able to become pregnant be enrolled, commit to using two forms of birth control and be tested for pregnancy monthly.

The program was updated in 2021 to include two categories — those who can become pregnant and those who cannot become pregnant — rather than male or female categories.

Dommasch recommends beginning with asking patients about the organs they have and if they are postmenopausal, as well as taking a sexual history being mindful of using the correct terminology.

If the patient is sexually active with men, intrauterine devices, Dep-Provera, Nexplanon implants or estrogen-containing birth control could be options, but she warns that many transmasculine patients may not be comfortable with these.

In addition to sensitivity around pregnancy, she advises careful monitoring of transgender patients on isotretinoin for mental health changes.

“This population has high rates of depression, so this is going to be something you really want to be asking about every month,” Dommasch said.

An ongoing study of patients undergoing isotretinoin treatment showed the transmasculine population also on testosterone therapy to have a higher percentage of acne involvement, higher depression screening scores and lower quality of life scores at baseline. Interim results have shown that all were improved with isotretinoin treatment.

“Patients who were receiving testosterone got better throughout the treatment,” Dommasch said. “Their quality of life got better, and that result was maintained 6 months after they stopped.”