Hormonal and Mental Health Implications of Acne: Selecting Appropriate Treatments for Patients

Karan Lal, DO, MS, FAAD

Acne is one of the most common inflammatory skin disorders, driven in part by hormonal stimulation. This is why teenagers start to develop acne. Although many of us outgrow acne, transgender patients often deal with acne forever. One study from a children’s endocrinology clinic looking at children and adolescents transitioning from female to male found the incidence of acne to be 54% within 1 year of testosterone administration and 70% within 2 years of testosterone administration.¹ Patients transitioning from female to male are more likely to develop acne due to testosterone and progestin administration. Testosterone is prescribed to stimulate hair growth and increase muscle mass, and progestins are prescribed to stop uterine bleeding. Progestins have different androgenic potentials, with norethindrone and medroxyprogesterone being more likely to cause acne.² In the study mentioned earlier,² progestin use prior to or during hormone therapy was associated with a higher risk of developing acne.¹ This is crucial information for us as dermatologists to know, as we can recommend endocrinologists use less-androgenic progestins.

However, some patients may not want to take these less-androgenic or antiandrogenic progestins. This is where we come in and come up with a long-term plan, as acne is a long-term issue, with higher prevalence of acne associated with longer use of androgens. Complicating this scenario are mental health issues and concerns in transgender individuals. One study assessing mental health symptoms in transgender men who received testosterone found moderate to severe acne was associated with a greater likelihood of mental health symptoms, including depression and anxiety.³ For many dermatologists and dermatology clinicians, the presence of mental health issues in transgender patients may prevent treatment with isotretinoin.

In one case series of 12 transgender male patients with acne, 4 were deemed severe enough cases of acne to warrant isotretinoin initiation. Of the 4 patients, 2 needed to discontinue therapy due to development of clinical depression and attempts at self-harm. One patient did not have depression prior to initiation and had partial response after suspension of therapy along with addition of antidepressant medication. The other patient had an undisclosed history of anxiety and symptoms of sadness but did not tell the practitioner and, 4 months after therapy, attempted to harm himself. One of the 4 patients had a history of depression and started antidepressants at the same time as isotretinoin and had no problems. The last patient had no history or development of depressive symptoms on therapy.⁴ In my personal experience, all my transgender patients and most of my lesbian/gay/bisexual patients have a history of mental illness. Because of this, I ask all my patients with acne about their mental health and symptoms. I do this even if isotretinoin isn’t on the table, as acne is an evolving disease and it may be on the table later; early detection and treatment of mental health issues streamlines the process. Not to mention there is a mental health crisis and shortage of clinicians who provide counseling and/or medical management. If a patient has a history of depression and/or anxiety without a history of suicidal intent and is stable on medication, I prescribe isotretinoin without psychiatric clearance. If the patient has active clinical depression and is not on medical therapy, I have them address that for 3 months and want stability before initiation of treatment. For patients with a history of suicidal attempt, I get psychiatric clearance, and more often than not, the psychiatrist will allow isotretinoin and monitor the patient more regularly with telehealth visits.

In my experience, many of my transgender patients do not want to go on isotretinoin at the beginning because of social media and the negative connotations of isotretinoin (being an endocrine disruptor, suicide inducer, etc); thus, I try to build a relationship with the patient, develop their trust, educate at every visit, and then focus on isotretinoin.

Acne Treatment With Devices

Lasers and light-based devices such as broadband light (BBL), intense pulsed light (IPL), 1064-nm laser such as Aerolase Neo Elite, Accure, and AviClear are all great for managing acne in LGBTQ patients. BBL/IPL is done at 2-to-3-week intervals but is not recommended for medium and darker skin tones. Aerolase Neo Elite is a 1064-nm laser that works by decreasing acne-causing bacteria, decreasing inflammation, and heating sebaceous glands. It is safe for all skin tones and colors and is also done every 2 to 4 weeks until response is noted. Both BBL/IPL and 1064-nm lasers can be done while the patient is on other medical therapies, including isotretinoin. The barrier to these procedures is cost. All my LGBTQ patients are underserved and do not have the means to pay for these treatments. I discount these treatments for my LGBTQ patients given the significant burden of their disease, especially since this will be an ongoing treatment for them. Accure and AviClear are great isotretinoin alternatives and can be performed on all skin colors as well. If patients need isotretinoin and are not willing to go on medical therapy, this is the best option for them. It is a painful treatment but can be performed while the patient is on topical and/or oral antibiotic therapy. It too is costly (around $3000) for the treatment series. The issue is this was not primarily studied in LGBTQ patients, so the longevity of results that is quoted does not necessarily apply to LGBTQ patients, as especially those on hormonal therapy may require multiple treatments.

Oral and Topical Treatments

The biggest development in acne management for LGBTQ patients is the topical drug clascoterone 1% cream (Winlevi; Sun Pharma). It is the first topical antiandrogen therapy approved for moderate to severe acne in patients 12 years of age and older. This drug is my first-line go-to topical in transgender male and transgender female patients with acne. I also use this in gay men who are on testosterone supplementation. It is safe for all skin types. It is meant to be monotherapy, but realistically these patients often need multiple therapies to get the condition under control. From a retinoid perspective, I prefer to use trifarotene after typical tretinoin failures, as trifarotene targets the retinoic acid nuclear receptor gamma, which is more specific in the realm of acne pathogenesis and has been shown to improve atrophic acne scars as early as 2 weeks after use.⁵ Acne scarring is common in the type of acne transgender patients have, and acne scarring could contribute to further mental health issues. Because many of these patients may not have the means to pay for cosmetic treatments to address scarring, this is a great alternative that targets acne and associated scarring.

There is controversy regarding spironolactone and acne in transgender patients. Those of us who have a niche in this arena prefer to use it in patients transitioning from male to female for both acne and androgenetic alopecia. We do not like to use this in patients transitioning from female to male, as it can lead to menstrual irregularities and even gynecomastia.

Caring for Your Diverse Patients

Taking care of LGBTQ patients should be no different from taking care of any other patient, but it is very easy to make the interaction better. LGBTQ patients are vulnerable to many biases, stereotypes, and discrimination. Your staff is the first point of contact for a patient encounter. Educate your staff about using nonspecific language and avoiding addressing patients as Sir, Ma’am, Mr, and Mrs. Let patients know at the front desk they can include their pronouns on the intake form. Ask patients what they prefer to go by. For example, a patient named Stephanie may identify as a transgender man but has not had their name legally changed and prefers to be called Steph or Stephen. Ask the questions! The only time you can get yourself into trouble is by not asking. Never assume. Many patients, not just LGBTQ patients, have lost faith in the health care system, and these simple things can really impact their care and values outside of your encounter.

Next, make sure you ask patients what they are willing to do. For example, I usually say, “How aggressive do you want to be about the acne?” “Are you open to pills, or do you want to do topical medications?” “Are you interested in other modalities such as lasers, which are out of pocket but won’t interact with your other medications?” Another thing to keep in mind is men who have sex with men may use doxycycline as postexposure prophylaxis (PEP), and this could cause undue harm if a patient is on isotretinoin. I bring this up because people may not consider PEP a long-standing medication and may not include it in their medical history or medication list.

Don’t be afraid to take care of LGBTQ patients. These patients are a part of a strong, interwoven community, and helping one could open your door to many new patients. Ask the right questions, give patients time to open up to you, educate them at every visit, and let them educate you. I learn a lot of new things from my LGBTQ patients, and this type of relationship could introduce you to a new set of patients who are great cosmetic patients.

Karan Lal, DO, MS, FAAD, is the first and only dual fellowship-trained pediatric and cosmetic dermatologist at Affiliated Dermatology in Scottsdale, Arizona.

References

1. Chu L, Gold S, Harris C, et al. Incidence and factors associated with acne in transgender adolescents on testosterone: a retrospective cohort study. EndocrPract. 2023;29(5):353-355. doi:10.1016/j.eprac.2023.02.002

2. Schwartz BI, Bear B, Kazak AE. Menstrual management choices in transgender and gender diverse adolescents. J Adolesc Health. 2023;72(2):207-213. doi:10.1016/j.jadohealth.2022.09.023

3. Braun H, Zhang Q, Getahun D, et al. Moderate-to-severe acne and mental health symptoms in transmasculine persons who have received testosterone. JAMA Dermatol. 2021;157(3):344-346. doi:10.1001/jamadermatol.2020.5353

4. Campos-Muñoz L, López-De Lara D, Conde-Taboada A, Fueyo Casado A, López-Bran E. Depression in transgender adolescents under treatment with isotretinoin. Clin Exp Dermatol. 2020;45(5):615-616. doi:10.1111/ced.14194

5. Schleicher S, Moore A, Rafal E, et al. Trifarotene reduces risk for atrophic acne scars: results from a phase 4 controlled study. Dermatol Ther (Heidelb). 2023;13(12):3085-3096. doi:10.1007/s13555-023-01042-7