Dermatology and transwomen: Some recommendations

Sex reassingment poses challenges before, during, and after the transition. Patients should be accompanied by at least six medical specialties. This article takes a closer look at dermathological aspects.

Skin issues in sex reassignment and transgender hormone therapy are crucial for the physical and psycghological wellbeing of patients

Gender dysphoria often causes a high psychological burden for the affected individuals. And those undergoing sex reassingment to match their gender identity also have many challenges during and after the transition. Ideally, these patients should be accompanied along the way by at least six specialist disciplines: Endocrinology, Dermatology, Psychology, Surgery, Otorhinolaryngology and Speech Therapy. This article takes a look at the dermatological issues affecting transgender women.

Currently, there is still an under-diagnosis and under-treatment of dermatological diseases of transwomen and transmen. Transgender hormone therapy (also referred to cross-sex hormone therapy)  brings with it a very special dermatological symptomatology. In transmen it can be accompanied by acne, hirsutism and hair loss. In transwomen it may be accompanied by pseudofolliculitis barbae (PFB), hirsutism and melasma.

Transgender hormone therapy for transwomen may include estrogens, antiandrogens such as spironolactone (USA) or cyproterone (Europe), and Gonadotropin-releasing hormone (GnRH) agonists (UK).1 Estrogens cause a reduction in sebum production in the skin. At the same time, they are associated with an increase in epidermis thickness and melanocytes stimulation. Body odor is also influenced by estrogens. Already after 1 month, changes in transgender hormone therapy are noticeable in the skin.2,3

The effective treatment of hirsutism in transwomen

Regarding the body hair of transwomen, there are still some specificities that require essential treatments for supporting the body perception of those affected. Transgender hormone therapy with estrogens and antiandrogens does not directly change the male hair pattern into a female one. Facial and body hair according to male distribution patterns can be treated by shaving, epilation, waxing or by topical application of eflornithine. Eflornithine is an ornithine decarboxylase (ODC) inhibitor that leads to a reduction in hair growth and is therefore used to treat hirsutism. The effect is based on an irreversible inhibition of the ODC enzyme. This reduces the division and differentiation of cells within the hair follicles. The therapeutic result sets in no earlier than 8 weeks after the start of therapy. 

An important side effect of eflornithine - affecting the external appearance - is acne. Bodily medical procedures should not be performed until hirsutism is reduced. If this is not the case, postoperative intravaginal and intraurethral irritation may occur due to hair follicles located on surgically inverted skin flaps. Preoperative permanent hair removal can be achieved by electrolysis or laser hair removal (LHR) of the follicles.4-7

The distressing pseudofolliculitis barbae (PFB)

PFB can result from frequent shaving. It can be associated with tremendous psychological distress for affected transwomen. After healing of the affected skin region, hyperpigmentation and keloid formation may occur. The use of topical retinoids and low-potency topical corticosteroids may provide relief.8-10
An essential dermatologic step before neovaginoplasty

In 2020, Carter et al published a protocol for safe and effective preoperative permanent hair removal in transwomen. Dermatologic care for transwomen is the focus here. Permanent hair removal can be performed by electrolysis or LHR. However, not all individuals are suitable for an LHR. LHR targets melanin and is therefore unsuitable for individuals with blonde or gray hair. For this group, only electrolysis is an option. In this method, the hair is removed via electrolytic current. For this purpose, a sterile probe is inserted along the hair canal into the respective hair root. 

Permanent hair removal should be performed by medical professionals. Before any treatment - be it with LHR or electrolysis - it is important to ascertain in the medical history whether a herpes simplex infection is present. In any case, permanent hair removal in the scrotum, perineum, and penile root areas should be performed before the planned neovaginoplasty to avoid subsequent intravaginal and intraurethral irritation. Mild erythema may occur after LHR. This can be treated with ice-packs (duration 5 min) and triamcinolone acetonide ointments at 0.025%. For the desired therapeutic result in this area, LHR should be performed every 4-6 weeks for a period of 6-9 months. Neovaginoplasty can be scheduled no earlier than 3 weeks to 3 months after this therapy interval.11, 12

1. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People.
2. Hembree W. C. et al. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab2017;102(11):3869–3903.
3. Stevenson S. et al. (2007). Effect of estrogens on skin aging and the potential role of SERMs. Clinical interventions in aging. 2007;2(3):283. 
4. Ginsberg BA. (2017). Dermatologic care of the transgender patient. Int J Womens Dermatol 2017;3(1):65–67.
5. Hembree W. C. et al. (2009).  Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009;94(9):3132–3154.
6. van de Grift T. C. et al. (2016). Body Satisfaction and Physical Appearance in Gender Dysphoria. Arch Sex Behav 2016;45(3):575–585. 
7. WPATH Recommended Benefits Policy Document: Created in Partnership with Starbucks. World Professional Association for Transgender Health;2018.
8. Bridgeman-Shah S. (2004). The medical and surgical therapy of pseudofolliculitis barbae. Dermatologic Therapy. 2004;17(2):158–163.
9. Perry P. K. et al. (2002). Defining pseudofolliculitis barbae in 2001: A review of the literature and current trends. Journal of the American Academy of Dermatology. 2002;46(2):S113–S119.
10. Yeung H, Kahn B, Ly BC, Tangpricha V. Dermatologic Conditions in Transgender Populations. Endocrinol Metab Clin North Am. 2019;48(2):429-440.
11. Downing J. M. et al. (2021). Hair Removal for Patients Undergoing Feminizing Surgeries in Oregon’s Medicaid Program. JAMA Dermatol. 2021;157(3):346–348.
12. Carter E. E. et al. (2020). Presurgical Laser Hair Removal: Protocoling a Safe and Effective Procedure for Transgender Patients. Transgender Health Volume 00, Number 00, 2020 a Mary Ann Liebert, Inc.

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