Beginning gender-affirming therapy can be an exciting time in your life. If you’ve decided to use testosterone, you likely look forward to changes, such as a deeper voice, facial hair growth, and bigger, stronger muscles. When you start to see these changes, you may notice one you hadn’t thought about — acne.
To help you treat acne successfully, we spoke with two board-certified dermatologists, who are known for treating acne and other skin conditions that can develop during gender-affirming therapy.
To clear acne, do you need to stop gender-affirming testosterone therapy?
No. However, it’s not unusual to believe this is your only option. I’ve seen patients stop their gender-affirming therapy entirely when acne became more than they could tolerate. That’s unfortunate and unnecessary.
Dermatologists treat testosterone-induced acne, and you can continue your gender-affirming therapy while treating acne.
─ J. Klint Peebles, MD, FAAD
I support whatever my patients want to do. However, before they stop therapy or reduce their dose, I tell them this. With a dermatologist’s help, you can successfully treat acne and keep your dose of testosterone where it is.
─ Elizabeth Damstetter, MD, FAAD
Why does acne develop after starting testosterone therapy?
When testosterone is part of your gender-affirming journey, the likelihood of developing acne increases because of the hormone. “However, taking testosterone isn’t a guarantee that you’ll see acne,” says board-certified dermatologist Elizabeth Damstetter, MD, FAAD.
“Acne develops for many reasons,” says board-certified dermatologist J. Klint Peebles, MD, FAAD. Dr. Damstetter adds, “Hormones are a key driver, but other causes can play a role. These include genetics, stress (which creates its own hormonal issues), and medications.”
Wearing non-breathable fabric like polyester or spandex, having sports equipment next to your skin, using skin care products that can clog your pores, or scrubbing your skin clean — these all can contribute to acne. Dr. Peebles says, “For these reasons, dermatologists never assume that an individual’s breakouts are due solely to their gender-affirming treatment.”
“When acne develops after starting testosterone therapy, it can continue for a long time,” Dr. Peebles adds. “Not long ago, we thought that it would eventually stop worsening and gradually get better, if not completely go away. However, we’re finding that acne can be persistent, meaning it continues to stay around for some time,” he says.
Why is this type of acne so persistent?
The increase in testosterone triggers your skin to make more sebum, an oily substance. This extra sebum can clog your pores, leading to whiteheads, blackheads, and pimples.
The increase in testosterone can also cause inflammation, which can lead to severe acne. Dr. Damstetter says, “Adults can have severe acne flares after starting hormone therapy.”
If you develop acne while taking testosterone, you may have a type of acne called hormonal acne. This type tends to develop on the lower third of the face, chest, upper arms, and back. It often appears within 2 years of starting testosterone therapy.1 It can also develop within months of starting testosterone.
Clearing hormonal acne often requires a dermatologist’s help.
Is there anything that can prevent acne while taking testosterone?
Because acne develops for many reasons, it’s difficult to prevent.
Keep in mind, there’s no reason to rethink taking testosterone because acne might develop. Not everyone who uses testosterone for gender-affirming therapy develops acne. If acne develops, it’s highly treatable.
Dr. Damstetter says, “Reducing your dose won’t necessarily make acne go away.”
Dr. Peebles shared other reasons for not reducing or stopping testosterone therapy. Testosterone plays a key role in gender affirmation for many people who are transgender or gender diverse. The doctor who planned your therapy carefully chose the dosage of testosterone to meet your specific goals. Modifying the dosage without medical guidance may mean that you won’t achieve your desired affirmation and gender expression. And if you stop testosterone suddenly, some of the male traits that you’re seeing may go away.
A dermatologist can help you gain control over acne while you continue your gender- affirming journey.
How do dermatologists treat acne that develops after starting testosterone therapy?
If you see a dermatologist when you first notice acne and it’s mild, your dermatologist may start you on a treatment plan that uses acne medications you can buy without a prescription. Dr. Damstetter says, “Products that contain adapalene, benzoyl peroxide, or salicylic acid are good options.”
Dr. Damstetter cautions that while treating mild acne, you can develop widespread acne, deep-seated nodules and cysts, or both. She encourages you not to be discouraged. Tell your dermatologist about the change. You’ll need a different treatment plan, but you can keep your testosterone dosage where it is.
When acne becomes moderate to severe, you’ll likely need prescription medication like isotretinoin. “With a dermatologist’s guidance, this is often an effective treatment for acne triggered by testosterone,” says Dr. Peebles.
Keep in mind that isotretinoin isn’t the right choice for everyone with testosterone-induced acne. When a dermatologist creates an acne treatment plan, it’s individualized for each patient.
While planning your treatment, your dermatologist will also consider any planned gender-affirming surgery. If surgery is upcoming, it may affect your treatment plan. Dr. Damstetter says, “Your dermatologist will optimize your treatment as best they can during this time, so you can have surgery and continue treating acne.”
Dr. Peebles points out that one of the key differences between an acne treatment plan created for a gender-diverse patient taking testosterone and one created for a cisgender patient with hormonal acne is the amount of time that each patient needs for treatment. If you’re taking testosterone, acne tends to be more persistent. You may need to treat it for a longer time.
Dr. Peebles cautions, “A longer treatment time isn’t always necessary, but I like to set realistic expectations.”
When you get your acne treatment plan, it will likely include an acne skin care routine. The right skin care helps you get the best results from treatment.
Skin care is important because it can make the difference between acne clearing or not clearing. For example, if you scrub your face clean, you irritate your skin. Any time you irritate your skin, acne can flare — even when following an effective treatment plan.
Dr. Damstetter says, “Acne isn’t the only skin or hair condition that can occur while you’re taking gender-affirming testosterone.”
Your dermatologist can talk with you about another condition that may have developed on your gender-affirming journey. For example, if you’re chest binding, your dermatologist can help with this, too. Dr. Peebles says, “There are a variety of techniques, strategies, and binding products. Some may be more appropriate and safer for you than others.”
Dr. Peebles adds, “Even with safe and appropriate use of binders, some patients develop skin conditions, such as acne, folliculitis (often looks like acne), or an infection. A dermatologist can treat these conditions and show you ways to prevent another flare.”
How to find a dermatologist you feel comfortable with
While all dermatologists can treat skin and hair conditions that can occur due to gender-affirming therapy, you may feel more comfortable seeing a dermatologist who has a special interest in caring for gender-diverse people.
Keep in mind when you go to a clinic that specializes in caring for gender-diverse people, you may not find a dermatologist on staff. By seeing a board-certified dermatologist who has a special interest in caring for gender-diverse people, you’ll get the expertise required to deal with hormonal acne and other conditions that can affect your skin or hair while continuing your gender-affirming therapy. No one knows your skin better than a board-certified dermatologist.
1 Radi R, Gold S, et al. “Treating acne in transgender persons receiving testosterone: A practical guide.” Am J Clin Dermatol. 2022;23(2):219-229. doi: 10.1007/s40257-021-00665-w.
Images
Courtesy of J. Klint Peebles, MD, FAAD, and Elizabeth Damstetter, MD, FAAD
References
Radi R, Gold S, et al. “Treating acne in transgender persons receiving testosterone: A practical guide.” Am J Clin Dermatol. 2022;23(2):219-229. doi: 10.1007/s40257-021-00665-w.
Written by:
Paula Ludmann, MS
Reviewed by:
Brendan Camp, MD, FAAD
Elizabeth Damstetter, MD, FAAD
William Warren Kwan, MD, FAAD
J. Klint Peebles, MD, FAAD
Carla Torres-Zegarra, MD, FAAD
