Treating the Chest with Care on a Transgender Patient

Matthew Mansh, MD, assistant professor and co-director of the High-Risk Non-Melanoma Skin Cancer Clinic at the University of Minnesota Medical School, focused on the care of transgender patients and breast procedures during the session “Behind the Bra: What Dermatologists Should Know About Diseases of the Breast” at the 2023 American Academy of Dermatology (AAD) Meeting in New Orleans, Louisiana.¹

Matthew Mansh, MD/University of Minnesota Medical School

“According to a JAAD study², both trans men and trans women expressed that their chest was a top priority to treat,” Mansh explained. “Gender-affirming hormone therapy, clothing, or surgery can impact the tissue growth and skin on the chest, so it’s important to know what to expect when trans patients come to your practice. These patients tend to be in younger generations.”

He shared what gender affirming procedures and treatments look like before delving into breast care in the dermatology space. Transmasculine and transfeminine journeys have different effects on the chest. Trans men may undergo hormonal therapy or wear compressive wear to hide breasts, which can both cause various forms of acne.

Masculinizing Hormone Therapy (MHT) involves testosterone taken orally, through a transdermal patch, gel, IM, or subcutaneous. MHT promotes the development of secondary sex characteristics associated with an individual’s gender identity. Transgender men may notice an increased amount of acne vulgaris, facial and body hair, and hair density. While the hormone therapy decreases the risk of breast cancer and the amount of glandular tissue, it does increase the amount of fibrous connective tissue. A study of MHT patients (n=988) using ICD-codes for acne vulgaris increased from baseline 6.3% to 31.1%, while a study of patients receiving MHT had an increase of facial acne from baseline 35% to 82% and an increase in truncal acne from baseline 15% to 88%.³

“When you have a trans patient undergoing hormonal therapy, it’s important to ensure adequate training of staff, trainees, and providers to promote a welcoming environment, be familiar with gender-inclusive language, and ensure patient intake forms and electronic health records are inclusive of transgender and diverse individuals,” Mansh expressed. 

Mansh has a routine when he sees a trans patient to manage their acne vulgaris. He said it’s essential to review the patient’s current MHT regimen including duration, type, dose, and frequency. Then, review the patient’s serum testosterone levels and work alongside their hormone providers to optimize dosing regimens to balance gender-affirming goals with unwanted side effects. He usually prescribes a topical retinoid+/- topical antibiotic and benzoyl peroxide, +/- oral antibiotic, combined oral contraceptives, or oral contraceptives. He notes spironolactone shouldn’t be used and reproductive potential should guide contraceptive counseling when potentially prescribing teratogenic medications.⁴

For moderate-to-severe nodulocystic acne, Mansh recommends oral isotretinoin. When discussing this treatment option with the patient, assess reproductive potential, discuss plan for intended gender-affirming invasive surgeries as this could impact timing, consider higher cumulative goal doses, and perform lab monitoring just like you would with a cis-gender patient.

If a trans male patient pursues top surgery to remove breasts, it often comes with noticeable scarring, which can be embarrassing for some patients. If that’s the case, laser therapies can be used to flatten and lighten the scar. Keyhole scarring around the nipple is also common. 

In a male-to-female transition or feminizing procedures, patients will have an increased amount of breast tissue with hormonal therapies. If they pursue top surgery, there are challenges that come with breast augmentation. Surgeons are presented with a challenge because there is less skin, a need for wider implants with rib cage width, and nipples must be moved. Illicit silicone, commonly used in body contouring, should not be used for breast augmentation because complications can arise from the silicone migrating to muscle or lymph nodes, causing infections and inflammatory issues.

Transgender patients are all prone to breast cancer because there is still breast tissue. Breast exams on both trans men and trans women can be performed the same way as they would be on cis-gender counterparts.

Mansch also noted The American Academy of Dermatology Association (AADA) has been working closely with the US Food and Drug Administration (FDA) to revise the iPLEDGE program to update verbiage this year to reclassify patients as either “patients who can become pregnant” or “patients who can not become pregnant.” The move is more inclusive of trans patients.⁵

References

1. Mansh M, Markova A, Murase J, et al. Behind the bra: What dermatologists should know about diseases. Presented at American Academy of Dermatology 2023 Annual Meeting; March 17-21, 2023; New Orleans, LA.

2. Ginsberg BA, Calderon M, Seminara NM, Day D. A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community. J Am Acad Dermatol. 2016;74(2):303-308. doi:10.1016/j.jaad.2015.10.013

3. Thoreson N, Park JA, Grasso C, et al. Incidence and factors associated with acne among transgender patients receiving masculinizing hormone therapy. JAMA Dermatol. 2021;157(3):290-295

4. Boudreau D, Mukerjee R. Contraception care for transmasculine individuals on testosterone therapy. J Midwifery Womens Health. 2019;64(4):395-402.

5. Mansh MD, Nguyen A, Katz KA. Improving dermatologic care for sexual and gender minority patients through routine sexual orientation and gender identity data collection. JAMA Dermatol. 2019 Feb 1;155(2):145–6.