Prescribing Isotretinoin for Transgender Patients: A Call to Action and Recommendations

January 2021 | Volume 20 | Issue 1 | Editorials | 106 | Copyright © January 2021


Published online December 12, 2020

Daniela P Sanchez BSa,b, Nicholas Brownstone MDb, Quinn Thibodeaux MDb, Vidhatha Reddy BAb, Bridget Myers BSb, Stephanie Chan BSb, Tina Bhutani MDb

aBoston University School of Medicine, Boston, MA
bUniversity of California San Francisco, Department of Dermatology, Psoriasis and Skin Treatment Center, San Francisco, CA

Abstract
Case Scenerio: A 26-year-old patient presents to the dermatology clinic with severe nodulocystic scarring acne. The patient identifies as a transgender male and notes that he has been receiving hormone replacement therapy for the past 4 years with weekly intramuscular testosterone injections.

CASE SCENERIO

A 26-year-old patient presents to the dermatology clinic with severe nodulocystic scarring acne. The patient identifies as a transgender male and notes that he has been receiving hormone replacement therapy for the past 4 years with weekly intramuscular testosterone injections. He has not had any gender-affirming surgeries and reports being currently amenorrhoeic. He is currently practicing abstinence. The patient has had his gender category legally changed to male on his driver’s license. He reports a long history of moderate acne, which significantly worsened after beginning masculinizing hormonal therapy with testosterone. The patient has tried doxycycline in the past as well as topical therapies including benzoyl peroxide with limited success and is now interested in isotretinoin therapy. The dermatologist notes that iPLEDGE requires physicians to register patients in one of three categories: male, female of non-childbearing potential, or female of child-bearing potential. The dermatologist should:

A. Agree to start the patient on oral isotretinoin and register the patient as “female of childbearing potential” according to the patient’s sex assigned at birth and follow iPLEDGE requirements for “female of childbearing potential.”
B. Agree to start the patient on oral isotretinoin and register the patient as "male” according to their gender identity and legal gender but follow iPLEDGE requirements for “female of childbearing potential.”
C. Agree to start the patient on oral isotretinoin and register the patient as “male” according to their gender identity and legal gender and follow iPLEDGE’s requirements for male patients only.
D. Not offer oral isotretinoin treatment because the category of “male of childbearing potential” does not exist within iPLEDGE’s patient registration schematic.

DISCUSSION

Transgender health has traditionally been neglected in medicine; however, recent interest in improving health care for transgender and other gender diverse persons has greatly increased.1 In the past decade, the medical community has taken steps toward mitigating the barriers to health faced by transgender individuals, and the field of dermatology is increasingly recognizing its critical role in providing non- discriminatory, gender-affirming care for transgender patients.2

The UCLA Williams institute reports there are currently 1.4 million adult Americans who identify as transgender.3 88% of female to male transgender individuals (transgender men) will develop acne within 4-6 months of testosterone administration.2,4 Administration of testosterone can increase levels of androgens at the pilosebaceous unit, leading to androgen-induced sebocyte growth and differentiation as well as increased sebum production and infundibular keratinization.4 This mechanism is thought to underlie testosterone-induced acne given the role elevated sebum excretion plays in acne pathophysiology. Severity of testosterone-induced acne in transgender men is variable, but it can be severe with some patients developing severe inflammatory acne with scarring.5 Typical first line agents for acne such as topical therapies and systemic antibiotics may be insufficient for complete management of testosterone-induced acne, and escalation of treatment is often required.4,5

There are currently no evidence-based best practice guidelines for the treatment of testosterone-induced acne.2 Thus, the treatment escalation algorithm is similar for transgender men and cisgender (non-transgender) individuals, with some key differences.2 Hormonal therapy with spironolactone (aldosterone receptor antagonist with anti-androgen activity) is not appropriate for transgender men who are on hormonal therapy as it could potentially negate the desired masculinizing effects of testosterone therapy.6 Furthermore, hormonal contraceptives such as combined oral contraceptive pills are not indicated for transgender men on masculinizing therapy.7 Other contraceptive options are less likely to interfere with masculinizing hormone therapy in transgender men, including intrauterine devices, injectables (Depo Provera), and transdermal implants (Nexplanon), however, these may not necessarily aid in the management of acne vulgaris.6,8 Thus, isotretinoin remains an effective and viable treatment option