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.
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