8th July 2020

Acne & Transgender Dermatology - Dr Anjali Mahto

RS PR of the day 08.07.2020

Words by Dr Anjali Mahto, Consultant Dermatologist at Skin55 & Author of The Skincare Bible:
I wanted to talk a little about issues in dermatology related specifically to the transgender community. This has been on my mind for quite sometime and earlier this week I scribbled up findings which form the basis of this post. Needs of the community are often unique and the scientific literature is sadly lacking. Transgender patients face healthcare barriers (discrimination and stigmatisation), economic marginalisation as well as a lack of access to healthcare professionals who are both knowledgeable and culturally sensitive to issues of health.  
There is a lack of representation of transgender skin issues in dermatology curriculums. Dermatologists (and doctors in general) need to be inclusive and compassionate to our patients. It is important not to make assumptions regarding gender identity, choice of pronoun or sexual orientation. It is also no more appropriate to assume that all transgender patients who attend our clinics want hormonal treatments or gender-affirming surgical procedures. The one thing I have learned in clinic is simply to be respectful and ask your patient how they want to be addressed and what they want. It seems so simple yet can be done so badly and threaten ruin of the doctor-patient relationship.
Dermatological conditions unique to this subgroup of patients include effects of hormonal related therapy; transition can affect skin health. Transgender men taking androgens (such as testosterone) often experience worsening of acne affecting the face and back. This usually peaks at 6 months of treatment and starts to improve after about 12 months.  Severe or scarring acne may require treatment with isotretinoin (Roaccutane). Adolescent transgender men who already have moderate to severe acne are those at highest risk of their skin flaring during hormonal treatment. These patients may also require close monitoring of their liver blood tests (testosterone can cause raised liver enzymes and potentially so can isotretinoin).  
Administration of testosterone will also increase body hair and may lead to male-pattern hair loss (androgenetic alopecia). Of transgender men receiving androgen treatment on average for 10 years, 30% will develop scalp hair loss. Testosterone will alter body physique and overall body fat. Conversely, therapy with oestrogen and anti-androgens in transgender women can also lead to specific skin changes including dryness, eczema and brittle nails. Whilst there will also be a reduction in body hair, additional measures are likely to be needed to remove any remaining or unwanted hair.
From an acne point of view, there are many things to consider, particularly in a male transgender patient which is what triggered me writing this post. Because of prescribing rules and pregnancy testing requirements, as a dermatologist, I need to think about potential reproductive capacity and how best to sensitively address this in clinic. Done badly, without explaining context this can alienate patients and prevent them seeking further interaction with healthcare - I don’t want this; the solution may be as simple as an “opt out of pregnancy prevention programme” in the UK and signing a waiver but this needs to be explained and discussed. For patients who are receiving testosterone and about to embark on isotretinoin, it requires honesty in saying that as doctors we don’t know if long-term remission from acne is possible. Long-term testosterone use may or may not continue to drive acne - we simply don’t have the data to definitively answer this question. Lastly, depressive symptoms and self-harm are more common in the transgender population than the cisgender population and there is also a relationship between acne and anxiety/depression. Patients need close monitoring for mood changes but treatment of acne may be life-changing in terms of confidence and self-esteem.
This post barely skims the surface and there are many more issues relating to hair, diagnostic challenges, minimising scars from surgery sites, as well as non-surgical treatments which could be considered. However, I wanted to start with acne which is not only common but its treatment can have profound effects on self-esteem and body image. As a health professional, I need to be aware that I am serving the needs of all the population and as a human being, I can also do with being a better ally to all marginalised communities.

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