Dermatological care of trans men should be lifelong

Transgender hormone treatments can be accompanied by difficult-to-treat dermatological changes in both trans women and trans men.

What skin conditions can transgender hormone therapy lead to in trans men?

The path to one's own identity - internally and externally - is not always so easy. In people with gender discrepancy, the external gender differs from the subjective gender experience. The path to the appropriate outer gender can often be a long one and is associated with surgical interventions and hormone treatments. These transgender hormone treatments are scheduled for a longer period of time and can be accompanied by dermatological changes in both trans women and trans men. The extent of the skin condition depends on genetic predisposition, age, dosage of the hormones as well as the individual initial situation. The masculinisation of the skin takes place more quickly than the feminisation of the skin of the trans women and trans men affected. Currently, the scientific studies in this area are still incomplete, so that no reliable long-term prognoses can be made on this topic. Today's special topic covers the skin problems of trans men.1-3

Troubled skin can be an enormous psychological burden for the person affected. Transgender hormone therapy in trans men can be associated with the following dermatological side effects: Hormone therapy can cause seborrhoea, acne, androgenic alopecia and hirsutism. The testosterone taken is converted in the body to dihydrotestosterone. It is possible that this conversion process differs between the sexes. Dihydrotestosterone is the biologically strongest androgen and thus the main cause of the side effects mentioned above.

As transgender hormone therapy is a lifelong therapy, it is important to manage the side effects effectively and to support the patient in this challenge as much as possible. There are some important things to keep in mind: Hirsutism in trans men is not treated with anti-androgens but with local therapies such as laser epilation. Minoxidil is used for androgenic alopecia. Acne can be treated locally or systemically with antibiotics and retinoids.1-3

Isotretinoin offers hope for hormone-related inflammatory acne in trans men

Already in 2015, several case reports were published on the therapy of inflammatory acne associated with mild and severe scarring in trans men. In the first case, the young trans man with mild inflammatory acne with scarring in the area of the face and chest could be successfully treated with isotretinoin. Therapy with another topical retinoid had previously been unsuccessful for 4 months. Testosterone therapy (1,000mg every 3 months), which was started 6 months earlier, had been the trigger for the skin problems. Oral isotretinoin therapy (30mg per day) finally cleared the inflammatory acne after 9 months. However, a relapse occurred due to discontinuation of the therapy. Re-treatment with 20mg isotretinoin daily again led to therapeutic success.

The second case was a young trans man with inflammatory acne with severe scarring in the face and chest region. Again, transgender hormone therapy (testosterone undecanoate 1,000mg every 3 months) had been the trigger. Isotretinoin therapy (20mg daily) led to complete healing of the inflammatory acne after 8 months. Six months after discontinuation of therapy, the acne also flared up again in this case. Doxycycline resistance was found, so that isotretinoin therapy (20mg isotretinoin 3 times per week) was started again, which led to the desired therapeutic success.4

What is isotretinoin?

Isotretinoin belongs to the group of active ingredients called retinoids and is used as a second-line treatment for severe acne. It has sebostatic, anti-inflammatory, anti-proliferative, proapoptotic and in some ways antibacterial properties. By reducing the size of the sebaceous glands and the formation of sebum, the Propionibacterium acnes is deprived of its substrate. In this way, bacterial colonisation can be counteracted. The side effect profile includes dry skin, eczema, chapped lips, ocular sicca symptomatology, conjunctivitis, muscle and joint pain and an increase in triglycerides. Isotretinoin may also be associated with mood swings. Caution should also be exercised in people with asthma, as they may experience marked breathing difficulty in the event of an allergic reaction to isotretinoin. In case of an increased urge to urinate and an increase in the feeling of thirst, a clarification of the blood sugar values should be carried out without fail, as diabetes mellitus can occur during isotretinoin therapy.5-7

Lifelong dermatological care of trans men is essential in order to be able to carry out a timely adjustment of therapy or a timely change of therapy if adverse health effects occur.

1. Boos M.D. et al. (2019). Prescribing isotretinoin for transgender youth: a pledge for more inclusive care. Pediatr Dermatol. 2019 Jan;36(1):169-171.
2. Mundluru S.N. et al. (2016). Unforeseen ethical challenges for isotretinoin treatment in transgender patients. Int J Womens Dermatol. 2016;2(2):46-48. published 2016 Apr 20.
3. Richer V. et al. (2020). Considerations in Treating Severe Acne With Isotretinoin in Transgender Men. Journal of Cutaneous Medicine and Surgery. 2020;24(5):529-530.
4. Turrion-Merino L. et al. (2015). Severe acne in female-to-male transgender patients. JAMA Dermatol. 2015;151(11):1260-1261.
5. Vallerand I. A. et al. (2018). Efficacy and adverse events of oral isotretinoin for acne: a systematic review. Br J Dermatol. 2018 Jan;178(1):76-85.
6. Costa C. S. et al. (2018). Oral isotretinoin for acne. Cochrane Database Syst Rev. 2018 Nov 24;11(11):CD009435.

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