A new population-level study highlights acne patterns in transgender individuals, helping clinicians better counsel and manage patients.
Transmasculine people had an eightfold higher risk of developing acne than cisgender men after initiating gender-affirming hormone therapy (GAHT), according to a large retrospective matched cohort analysis.
This risk peaked in the first year after initiating testosterone but remained high for the following five years.
Using US electronic health record data of more than 280,000 people, researchers analysed the trends of acne incidence and severity in the first five years after GAHT initiation.
“Patients should be counselled that acne is a common effect of testosterone and reviewed early after beginning GAH therapy,” Dr Yaron Gu, a researcher and junior medical officer at Gosford Hospital with a special interest in transgender and gender-diverse dermatology, told The Medical Republic.
Given the continued prevalence in this group, he said dermatological input would be valuable at any point but emphasised the importance of early referral.
But acne was not just a transmasculine issue, the study found.
“After oestradiol initiation, transfeminine individuals had a higher incidence of acne than matched cisgender men, highlighting a similar need for proactive assessment and management,” Dr Gu said.
Transgender and gender-diverse patients are a group that experiences significant health disparities, he said, and long-term population-level data to assist clinicians in advising these patients about acne when initiating GAHT is limited.
“[This study] helps fill this gap and adds to the existing body of evidence, which is useful for patient counselling and early management planning,” he said.
“Proactive monitoring and prompt escalation of standard acne treatments can reduce permanent scarring and psychosocial distress.
“Skin and hair play a role in and intersect with gender affirmation. Clinicians may encounter various dermatological considerations in transgender and gender-diverse patients, including androgenetic alopecia, hirsutism, and considerations around gender-affirming procedures (such as pre-operative hair removal and scar management).”
The study included around 11,000 transmasculine individuals, matched to 71,500 cisgender men and 69,000 cisgender women, and 9500 transfeminine individuals matched to 61,000 cisgender men and 60,000 cisgender women.
Mean age at index was 28 years for transmasculine participants and 33 years for transfeminine individuals. Inclusion criteria were the absence of baseline acne and a minimum age of 16 years between 2006 and 2022.
Acne incidence was based on diagnostic codes, and the prescription of isotretinoin or 30 or more days of oral antibiotics was used to classify acne as moderate to severe.
In the first year of GAHT, transmasculine individuals had a significantly higher risk of acne compared with matched cisgender men (HR 8.29) and more than double the risk compared with matched cisgender women (HR 2.63).
This cohort also experienced a higher rate of moderate to severe acne than matched cisgender men (28.9 vs 4.3 per 1000 person-years; HR 8.06) and matched cisgender women (7.7 per 1000 person-years; HR 3.76).
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Transfeminine individuals had a higher risk of acne after starting oestradiol than matched cisgender men (HR 1.56), but a lower risk than matched cisgender women (HR 0.53).
This group had equivalent rates of moderate to severe acne compared with matched cisgender men, but lower rates than matched cisgender women (2.1 vs 4.7 per 1000 person-years; HR 0.39).
Following this early surge, analysis of longer-term acne burden showed persistent differences between transgender individuals and their matched cisgender cohorts.
At five years, transmasculine individuals still had the highest cumulative incidence of acne (15.8%) compared with matched cisgender men (3.8%) and matched cisgender women (10.5%).
Five-year cumulative incidence of moderate to severe acne was 5.9% in transmasculine individuals, compared with 1.4% in matched cisgender men and 3% in matched cisgender women.
Transfeminine participants had a higher cumulative incidence of acne than matched cisgender men (6% vs 2.9%) but a lower incidence than matched cisgender women (8.4%).
Cumulative incidence of moderate to severe acne in transfeminine individuals was 1.4%, compared with 1% in matched cisgender men and 2.1% in matched cisgender women.
“Treatment patterns also differed by group,” Dr Gu explained.
Transmasculine individuals were more likely to receive topical retinoids, oral antibiotics and isotretinoin than matched cisgender women, and transfeminine individuals were less likely to receive oral antibiotics and isotretinoin than matched cisgender men.
“Transfeminine patients were more likely to receive spironolactone than cisgender comparators, reflecting its role in feminising GAH regimens as well as acne management,” he said.
“In these cases, shared management between gender-affirming care providers and dermatology, where needed, can help optimise dosing and monitoring while aligning treatment with the patient’s affirmation goals.”
“Acne should not be framed as a barrier for gender-affirming care, and management should remain individualised and patient-centred, as it should for all patients.”
