For transmasculine patients undergoing testosterone treatment, acne is more than just a transient side effect, says Howa Yeung, MD, MSc, an assistant professor of dermatology at Emory University School of Medicine in Atlanta, Georgia. (AE). Many patients require topical and oral treatments that may include isotretinoin, which creates unique challenges in this population.

“For transgender and gender-diverse patients who begin sex-affirming hormone therapy, their skin often responds to changes in hormone levels.”first Yeung said. For transmasculine patients, testosterone injections often increase the skin’s oiliness, promoting the development of acne, often during the first six months of treatment, he said. “Doctors think that basically the body gets used to testosterone and acne subsides after 1 to 2 years. It’s almost seen as fleeting [AE], a rite of passage. ”

However, new data suggests otherwise. “Acne is still common, persistent, and affects transgender and gender-diverse people,” says Yeung.

In separate cohorts of 928 and 55 testosterone-treated transmasculine patients, 31% and 38%, respectively, developed acne within 2 years.2.3 In a multicenter survey of 50 transgender men who received testosterone for an average of 10 years, 70% continued to report mild to moderate acne.4

Among 696 transgender adults surveyed by Yeung et al., 14% of transgender subjects reported currently having moderate to severe acne; Two-thirds of them associated acne with testosterone therapy.5 He added: “Patients taking transmasculine also saw fewer dermatologists.

Some observers see acne as a small price to pay for testosterone’s effect in promoting the mental health of transmasculine patients, Yeung said. “As dermatologists, we know that acne itself can negatively impact a patient’s mental health and quality of life.”

Among testosterone transmasculine patients surveyed by Braun et al, those with moderate to severe acne present were more likely to experience depression (71%) and anxiety (39%). than those who have never had acne.6 “Acne is important for transgender people and their mental health. We can help treat acne, as well as other unwanted breakouts [AEs] of hormone therapy, to ultimately improve the mental health outcomes of these patients,” according to the study.

Generally, Yeung says, the American Academy of Dermatology’s acne guidelines apply. “In moderate to severe cases, there are some specific concerns,” he said. “Many cases persisted when patients continued testosterone treatment.” Therefore, he suggests having an exit strategy whenever oral antibiotic therapy is prescribed.

Because systemic hormone therapies such as the combined oral contraceptive and spironolactone can have a feminizing effect, they are rarely used as first-line acne treatments in transmasculine patients. “Topical clascoterone, which blocks the effects of dihydrotestosterone on the skin, has been shown to be effective in the treatment of facial acne in men and women in 2 clinical trials.”7 Yeung said, adding that, unfortunately, these trials overlooked transgender patients.

Some experts recommend using topical clascoterone specifically to target the effects of testosterone on the skin.8 “It is hoped that future acne studies will provide more details on patient sex, gender, and hormone therapy use so that we can review safety and acceptability.” acceptance of these treatments in gender-diverse patients,” he said. “Until then, many patients with moderate to severe acne will eventually need isotretinoin to get a good long-term response.”

In the United States, the iPLEDGE system classifies patients based on the sex assigned at birth. “If you try to register a transmasculine patient as a male, you will receive a threatening message about the need to provide documentation, as well as the possibility of permanently losing your prescribing privilege.”

Yeung said asserting a patient’s gender identity on transmasculine while meeting federal regulations requires detailed discussions with the patient. Finally, he adds, a guide published by Fenway Health in Boston, Massachusetts, proves very helpful in educating transgender and gender-diverse patients about the birth control requirements of iPLEDGE.9

“For transgender and heterosexual patients of reproductive potential who do not abstain from sex with men or penile partners, two forms of contraception are required. [for isotretinoin prescription], ”ten he say. “Many dermatologists mistakenly believe that if you’re using testosterone, hormonal contraceptives are unfounded. That’s not right.”

Often, hormonal contraceptives can help reduce unwanted menstrual bleeding or menstrual pain, he said, particularly if amenorrhea is not achieved through testosterone alone. Conversely, non-thermal contraceptives such as the copper IUD can worsen menstrual bleeding and cramping, worsening dysmenorrhea.

“Discuss with a gender-affirming person [obstetrician-gynecologist], a family planning specialist or a reproductive health professional can often help a patient decide on a primary form of contraception, including long-acting contraceptives, that is right for them,” said Yeung. explain. In addition, the Family Planning Society has issued guidelines for counseling on contraceptives for transgender and gender-diverse individuals assigned to be female at birth.11

“Some dermatologists may refuse to prescribe isotretinoin because transgender and gender-diverse patients have a higher risk of depression and suicide,” he says. “I argue that this contributes to the disparities in skin health care that these patients already have.”

Typically, transgender patients who see a dermatologist have a good relationship with mental health care, Yeung said. “Isotretinoin visits provide a great opportunity for dermatologists to help center their patients’ multidisciplinary care with contraceptive counseling, hormone management, and vertical mental health care, as well as vertical mental health care, as monitor [AEs]. ”

Disclosure:

Yeung reported no financial interests involved. His research was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the Foundation of Dermatology, and the American Acne & Rosacea Society.

Presenter:

1. Yeung H. Acne in people of various genders. Presented at: American Academy of Dermatology VMX; Virtual. April 23, 2021.

2. Thoreson N, Park JA, Grasso C, et al. Incidence and factors associated with acne in transgender patients treated with virilization hormones. JAMA Dermatol. In 2021; 157 (3): 290-295. doi: 10.1001 / jamadermatol.2020.5347

3. Park JA, Carter EE, Larson AR. Risk factors for developing acne during the first 2 years after initiation of virilized testosterone therapy in transgender men. J Am Acad Dermatol. 2019; 81 (2): 617-618. doi: 10.1016 / j.jaad.2018.12,040

4. Wierckx K, Van Caenegem E, Schreiner T, et al. Cross-sex hormone therapy in transgender individuals is safe and effective when followed in the short term: results from the European Network of Gender Inequality Investigations. J Sex Med. 2014; 11 (8): 1999-2011. doi: 10.1111 / jsm.12571

5. Yeung H, Ragmanauskaite L, Zhang Q, et al. Prevalence of moderate to severe acne in transgender adults: a cross-sectional survey. J Am Acad Dermatol. Year 2020; 83 (5): 1450-1452. doi: 10.1016 / j.jaad.2020.02.053

6. Braun H, Zhang Q, Getahun D, ​​et al. Mental health symptoms and moderate to severe acne in transmasculine users who received testosterone. JAMA Dermatol. In 2021; 157 (3): 344-346. doi: 10.1001 / jamadermatol.2020.5353

7. Hebert A, Thiboutot D, Stein Gold L, et al. Efficacy and safety of clascoterone topical cream, 1%, for the treatment of patients with facial acne: two randomized phase 3 clinical trials. JAMA Dermatol. Year 2020; 156 (6): 621-630. doi: 10.1001 / jamadermatol.2020.0465

8. Signs of DH, Mansh MD. Potential role of topical antigen in the management of acne in patients treated with virilizing hormone therapy. JAMA Dermatol. Year 2020; 156 (12): 1380-1381. doi: 10.1001 / jamadermatol.2020.4380

9. iPLEDGE Guidelines for Transgender and Diversity Patients on isotretinoin. Fenway Health. Retrieved May 26, 2021. https://fenwayhealth.org/wp-content/uploads/Guide_to_-iPLEDGE.pdf

10. Krempasky C, Harris M, Abern L, Grimstad F. Transmasculine spectral contraception. Am J Product Gynecol. Year 2020; 222 (2): 134-143. doi: 10.1016 / j.ajog.2019.07.043

11. Bonnington A, Dianat S, Kerns J, et al. Clinical recommendations of the Society for Family Planning: Contraceptive counseling for transgender and gender-diverse people with female sex at birth. Contraception. Year 2020; 102 (2): 70-82. doi: 10.1016 / j.contraception.2020.04.001

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