Treating Severe Acne in Transgender Patients: An Update

Dermatologists are increasingly seeing transgender patients with acne and other skin or cosmetic concerns. Transgender is the umbrella term for people whose gender identity differs from what they were thought to be at birth. As many as 1.4 million adults and 0.7 percent of youth aged 13 to 17 identify as transgender, according to the Williams Institute.

Acne tends to flare in female-to-male (FTM) patients because testosterone is administered exogenously to elicit male secondary sex characteristics. Testosterone-induced acne is a documented side effect of testosterone replacement therapy.

Testosterone-induced acne in FTM patients typically occurs within the first six months of initiating therapy and may improve over time. Some FTM patients develop severe acne that requires isotretinoin; this acne often persists for as long as patients are on testosterone therapy. While isotretinoin is effective, acne recurs after discontinuation of the drug.

iPledge and FTM Patients: Special Considerations

But how do we enroll our FTM transgender patients taking isotretinoin into the iPledge program? This is not always as straight forward as it is with their cisgender counterparts. What is the status of transgender men in terms of iPledge and childbearing potential? The key phrase to consider in your assessment is reproductive potential. Testosterone greatly reduces the ability to become pregnant, but it does not completely eliminate the potential. In fact, ovary function is preserved in transgender men after one year of testosterone therapy. Any FTM patient who is sexually active with a genetically fertile male must use contraception if they are taking isotretinoin.

Pregnancies can and do occur in FTM patients. A study in Contraception by Light et al, found that 86 percent of 197 FTM study participants were taking masculinizing hormones, and 60 pregnancies were reported. Of these 60 pregnancies, 10 occurred after stopping testosterone and one while taking testosterone irregularly; five of seven abortions occurred in participants who had been using testosterone in the past. Over half of the respondents desired at least one child, and a quarter reported fears of not getting pregnant. The majority of participants reported contraception use, most commonly condoms and oral contraceptives.

The takeaway here is that a FTM patient taking testosterone and isotretinoin who has sex with men needs to use iPledge-compliant contraception. Options are limited because of exogenous hormone therapy, however a copper IUD is considered suitable. Abstinence from vaginal intercourse with a fertile male is also acceptable.

Isotretinoin, Acne, and Suicidality in FTM Patients

Isotretinoin use has been associated with suicidal ideation, but an evidence-based causal relationship has not been established. Transgender adults, however, are at higher risk for suicidality, depression, and anxiety, and this must be considered when deciding on therapy for acne, bearing in mind that severe acne is also associated with mental health issues. These patients should be monitored for mood symptoms by dermatologists, psychiatrists, general practitioners, family members, and loved ones.

As with all of our isotretinoin patients, monitoring liver function, serum cholesterol, and triglycerides at baseline and until response to treatment is established is essential.

What About MTF Acne Patients?

Isotretinoin and spironolactone can be used to treat acne in male-to-female (MTF) patients. Side effects of spironolactone are dose-related and may include breast tenderness, menstrual irregularities, and gynecomastia. In fact, the androgen blocking effects of spironolactone and gynecomastia are beneficial in these patients who are looking to achieve female secondary sex characteristics.

The risk of hyperkalemia has been largely disproven. I typically suggest that all patients who take spironolactone for acne avoid NSAIDs, salt substitutes, coconut water, ACE inhibitors, and Angiotensin II receptor blockers because they retain potassium, as does spironolactone.

Treating transgender patients for acne or cosmetic concerns does involve some special considerations, but dermatologist have the tools and expertise to meet their expectations and help them in their journey.

For more on the dermatologic care of transgender patients, read “Caring for the Transgender Patient” by Doris Day, MD from the December edition. Available at PracticalDermatology.com/issues/2020-dec.

Wierckx K, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med. 2014;11:222-229.

Turrion-Merino L, et al. Severe Acne in Female-to-Male Transgender Patients. JAMA Dermatol. 2015;151(11):1260-1261.

Ebede TL, et al. Hormonal Treatment of Acne in Women. J Clin Aesth Dermatol. 2009; 2 (12): 16-22

Light A, et al. Family planning and contraception use in transgender men. Contraception. 2018 Oct;98(4):266-269.

Presented at ENDO 2019, the Endocrine Society’s annual meeting. “Ovary function is preserved in transgender men at one year of testosterone therapy.”